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| Is Advanced Practice Nursing for
you? Nancy J. Brent, RN, MS, JD |
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| Each
type of advanced practice nursing has its own unique
character and flavor. Are you looking for a career change that offers more opportunities for autonomy, collaboration, and hands-on care? No need to search outside the nursing world. Advanced practice nursing is an option within the nursing profession for those who are independent, bright, and willing to meet a challenge head on. An advanced practice nurse (APN) is a registered nurse who has successfully completed an additional course of study in a specialty area of nursing that prepares the APN to function in an expanded role.1 Advanced practice nursing is regulated by state law and the state agency empowered with administering and enforcing the nurse practice act in the state. As such, requirements for advanced practice nursing may vary from state to state. For example, the additional course of study required depends upon state law. Some states require a master’s degree, while others combine the academic course of study with a minimum number of years of practice in nursing. Prescriptive authority, an essential part of the APN’s role, is granted by the state only upon completion of a state-approved pharmacology course. In addition, the examination required for certification by a nationally recognized certification body, such as the American Nurses Credentialing Center or the Council on Certification of Nurse Anesthestists, may vary from state to state, as well. State nursing boards decide pursuant to their powers to promulgate rules and the state rule-making requirements, which certifying organizations’ exams and subsequent certifications are acceptable in considering an applicant for an APN license in that state. There are four categories of advanced practice nursing: clinical nurse specialist (CNS), nurse practitioner (NP), certified nurse midwife (CNM), and certified registered nurse anesthetist (CRNA). Clinical Nurse Specialist According to the National Association of Clinical Nurse Specialists, the CNS is an expert clinician in a specialized area of nursing practice.2 Prepared with graduate education, the CNS’s speciality area can be based upon a specific population (e.g., geriatrics, women’s health) or a type of problem (e.g., pain, stress). Certification is not always possible because a certification exam does not exist for every area of specialty practice. As a result, many CNSs take an exam that does not necessarily reflect their specialty area of practice but most closely reflects the CNS’s practice and the state requirement for national certification. The CNS practices in a variety of healthcare settings, usually in one of five main areas of practice: clinical practice, teaching, research, consulting, and management.3 Regardless of the CNS’s role, research has indicated that using the CNS helps reduce costs and the length of stay of patients in inpatient units, improves pain management practices, and increases patients’ satisfaction with nursing care.2 The average annual earnings for a CNS in 2002 was $50,800. The National Association of Clinical Nurse Specialist’s figures indicate there are approximately 69,017 RNs who have the education and credentials to function as a CNS. In addition, its president, Janet Fulton, RN, PhD, says, “The job market is begging for CNSs.” Educational programs to prepare RNs for this role have increased in numbers. Currently, during the last three years, 40 new or revamped CNS educational programs have opened.3 Nurse Practitioner An NP, armed with either a certificate or a master’s degree, is an RN whose extensive education and clinical experience enables him or her to “diagnose and manage most common and chronic illnesses, either independently or as part of a healthcare team.”4 Indeed, the NP’s “strong emphasis” is primary care. The NP focuses on health maintenance, disease prevention, counseling, and patient education. These services are performed in a variety of healthcare settings, including acute care, home care, and mental health. Certification in the NP’s area of specialty practice is a mandatory requirement of NP educational programs and state licensure. Research on NP practice indicates that their contributions to quality, safe care are well documented. Generally, NPs prescribe fewer drugs than physicians, provide cost-effective care that results in a high patient satisfaction level, make diagnoses and develop treatment plans that are accurate and adequate.5 An NP’s average salary in 2002, based on 505 nurse practitioners who took part in the American College of Nurse Practitioner’s survey, was $66,125. The job market for NPs continues to be strong, particularly for bilingual NPs on both the East and West coasts and for NPs in rural and underserved areas of the country. Family NPs and acute care NPs are in high demand.3 Certified Nurse Midwife Approximately 68% of CNMs possess a master’s degree, while 4% hold doctoral degrees.6 Their education, along with the required certification by the American College of Nurse-Midwives Certification Council and state licensure, allows the CNM to provide primary care and case management to healthy women through family planning, pregnancy, childbirth, the postpartum period, and care of the newborn.3 Most often CNMs deliver infants in hospitals (99%), but they also deliver babies in freestanding birth centers (0.26%) as well as in the home (0.59%).6 The average nurse midwife takes care of 140 clients a month and attends 10 births a month. The CNM’s role also includes prescribing medications, working with patients with obstetrical and gynecological problems, consultation, and collaborative management with other health team members. Patient satisfaction with CNM services is high. In fact, the results of a recent national survey indicated that women with a college degree between the ages of 25 and 34, and who have an income of $20,000/year, will likely use a CNM for their future births.6 Another recent study documented the quality of care provided by CNMs. The findings indicated that low-risk patients who received “collaborative midwifery care” had birth success rates comparable to those who saw only physicians, with fewer interventions, more options, and lower costs to the healthcare system. The study is used by many to support the proposition that nurse-midwives, working in collaboration with physicians, should care for the majority of pregnant women in the US.7 Positions for nurse-midwives are most often found in hospitals and large birthing centers. The average, annual salary for a nurse-midwife is $57,600, according to MHA Health Careers Center. Certified Registered Nurse Anesthetist CRNAs administer anesthesia and anesthesia-related care in four general categories: preanesthetic preparation and evaluation; anesthesia induction, maintenance and emergence; postanesthesia care; and perianesthetic and clinical support functions.8 To do so, the CRNA must be a graduate of an accredited nurse anesthesia education program (master’s degree) and successfully pass the certification exam administered by the Council on Certification of Nurse Anesthetists. Like other APNs, the CRNA must also be a registered nurse and comply with any and all state regulatory mandates. CRNAs also provide consultation on anesthesia and anesthesia-related issues to MRI and interventional radiology units and cardiac catheterization centers; function as administrators in departments of anesthesia; and participate in research, as investigators, collaborators, consultants, assistants, interpreters, and users of research findings. Areas of concentration for the CRNA include pediatric, obstetrical, dental, or neurological anesthesia. Some CRNAs are also credentialed in other areas of nursing practice, such as critical care nursing. CNRAs practice in all types of healthcare settings: hospitals, dental offices, ambulatory surgical centers, and birthing centers, to name a few. Sixty-five percent of all patients receiving anesthesia for surgical or medical procedures are cared for by a CRNA.8 The current job market for CNRAs is excellent, according to the American Association of Nurse Anesthetists 2003 President Rodney Lester, CRNA, PhD. He believes this demand is due to the increasing numbers of aging individuals needing more surgical services, the flexibility of the nurse anesthetist to provide care in a variety of outpatient settings, and the continuing, strong demand for CRNAs in rural communities, inner cities, and medically underserved areas.3 The quality of CRNA care cannot be underestimated. In fact, studies have indicated that CRNAs provide “superb” anesthesia care. Moreover, one professional liability insurance underwriter’s premiums for nurse anesthetists decreased significantly from 1988 to 2001, further demonstrating that CRNAs provide safe anesthesia care.9 Salaries for CRNAs vary, but the median annual income for a CRNA in 2001 was approximately $113,000 based on an AANA Membership Survey.10 Lester believes that CRNAs have “tremendous opportunities to maximize their earning potential” while experiencing a unique level of autonomy.3 This brief overview of the four categories of advanced practice nursing highlights the unique aspects of each one and differentiates the practice of the APN from other nursing roles. Of course APN practice is not utopian. There are many obstacles to overcome, including regulatory limitations on practice, resistance to APN practice by physicians and others, reimbursement concerns, and the difficulty in gaining hospital privileges. Even so, every nurse who is thinking of leaving nursing because another profession’s grass looks greener over the proverbial fence might want to take pause and carefully study that grass. It may be that the opportunities as an APN are much “greener” than the grass on the other side of that fence.
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