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APN/APRN — What’s in a Name?

Monday June 30, 2008
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What makes a nurse an advanced practice registered nurse? Because of the nation’s hodgepodge of state regulations governing advanced practice, the answer is both elusive and confusing.

“Currently there is no generally accepted definition of advanced practice nursing from a regulatory perspective,” says Nancy Chornick, RN, PhD, CAE, director of practice and credentialing for the National Council of State Boards of Nursing. NCSBN has, however, identified an APRN as an RN who —

    • Has completed a program of study in an accredited nursing program in one or more of these categories: nurse practitioner (NP), nurse anesthetist (CRNA), nurse midwife (CNM), and clinical nurse specialist (CNS)

    • Has taken a certification examination in the same area for purposes of licensure/authority to practice

    • Has been authorized to practice by a state licensing board

Although this definition seems clear-cut, the advanced practice title isn’t. In some areas; the umbrella credential APRN is used; in others, advanced practice nurse (APN) is preferred. There is also a lack of standardization in educational preparation for some APRN roles. Complicating this is the fact that not all states recognize all four APRN categories. For example, Pennsylvania did not pass title protection legislation for CNSs until 2007.

There is also confusion about which nurses with advanced degrees are actually APRNs, such as some nurses educated to work in education, administration, and informatics.

“Although they have graduate degrees and an excellent contribution to make, they are not categorized as APRNs if they are not offering direct clinical care to patients and are not certified in advanced practice,” says Charlene “Chuckie” Hanson, RN, EdD, FNP-BC, FAAN, a consultant to the National Council of State Boards of Nursing APRN Advisory Panel. She is also professor emerita in nursing at Georgia Southern University. Hanson is currently involved with an ongoing effort by NCSBN and a consortium of advanced practice leaders to develop and recommend a new regulatory model to clarify titling and regulation of advanced practice.

“To protect the public, we have to be able to draw lines around who is and isn’t able to be an APRN,” she says.

NPs: Multifaceted Specialists

NPs have provided healthcare services in a variety of settings for more than 43 years and diagnose and treat a wide range of health problems.

“Our role is to provide very high-quality and cost-effective healthcare. We address both acute minor illnesses and complex chronic illnesses and integrate health promotion and disease prevention in everything that we do,” says Mary Jo Goolsby, RN, EdD, NP-C, FAANP, director of research and education for the American Academy of Nurse Practitioners.

NPs are licensed in all states and the District of Columbia, and most are nationally certified in their specialty area, according to the American Academy of Nurse Practitioners. There are five NP certifying bodies, and each certifies one or more NP specialties, which include: Acute Care, Adult Health, Family Health, Gerontologic Health, Neonatal Health, Oncology, Pediatric/Child Health, Psychiatric/Mental Health, Women’s Health.

An NP’s scope of practice varies because every state currently regulates practice according to its individual Nurse Practice Act. The major differences in practice are due to variations in the written collaborative agreements with physicians that most states require. However, in all states NPs can:

    • Order, perform, and interpret diagnostic tests, such as lab work and X-rays

    • Diagnose and treat acute and chronic conditions such as diabetes, high blood pressure, infections, and injuries

    • Prescribe medications and other treatments

    • Manage patients’ overall care

    • Counsel patients and help them

    • Help patients learn how their actions affect their health and well-being

“We are recognized as independently licensed providers,” says Goolsby. “About 67% of NPs function as primary care providers outside of the hospital in the community where people see us as their main source of health care.”

Clinical Nurse Specialists: Experts in Quality and Safety

Clinical nurse specialists are expert clinicians in a specialized area of nursing practice. “Quality and safety is the hallmark of CNS practice. Many healthcare executives refer to CNSs as the glue that keeps the system together,” says Christine Carson Filipovich, RN, MSN, CNS, chief executive officer of the National Association of Clinical Nurse Specialists.

According to the National Association of Clinical Nurse Specialists, CNSs have practiced in a wide variety of healthcare settings for more than 50 years and impact care at three levels:

CNSs are experts in clinical care and contribute to identifying, intervening, and managing clinical problems to improve the delivery of care. Increasingly, states are recognizing that CNSs are educated and credentialed to diagnose and prescribe pharmacological and nonpharmacological treatment of health problems, according to Janie Heath, RN, PhD, APRN-BC, FAAN, associate dean, academic affairs, at the Medical College of Georgia in Augusta.

CNSs influence care outcomes and assist staff to give the most up-to-date care by providing expert consultation and modifying plans of care by bringing evidenced-based care to the bedside. In some cases, depending on the setting, state regulations, and individual hospital policy, CNS practice may also include prescriptive authority, including ordering durable medical equipment, consultations with other disciplines, and diagnostic tests/surveillance. CNSs evaluate care across the whole system and implement interventions to improve patient outcomes across the entire healthcare system.

Clinical expertise and specialization of the CNS are founded on graduate programs that prepare CNSs. Scope of practice varies between states and is defined by each individual state's Board of Nursing. The new regulatory model will help standardize scope of practice across states.

Currently CNSs and certifiers are working to develop certification exams in areas where no exam exits. Specialties for which certification is available include —

    • Child/Adolescent Psychiatric Mental Health Nursing

    • Adult Psychiatric Mental Health Nursing

    • Medical/Surgical Nursing

    • Gerontological nursing

    • Community Health Nursing

    • Home Health Nursing

    • Pediatric Nursing

    • Orthopedic Nursing

    • Oncology Certified Nurse (AOCN)

    • Certified Rehabilitation Registered Nurse — Advanced (CRRN-A) certification

    • Adult, Pediatric, and Neonatal Acute Care

    • Critical Care CNS (CCNS)

Certified Registered Nurse Anesthetists: Masters of Anesthesia and Pain Management

Nurse anesthetists have been practicing in the U.S. since attending to the anesthesia needs of wounded soldiers during the Civil War. They have also been the main providers of anesthesia care to U.S. military men and women on the front lines since WWI. Today CRNAs are the primary anesthesia providers in rural America and are the sole providers in nearly 100% of the rural hospitals in some states. “The specialty of anesthesia actually started in nursing,” says Jackie Rowles, RN, CRNA, MBA, FAAPM, president elect of the American Association of Nurse Anesthetists.

The credential certified registered nurse anesthetist (CRNA) came into existence in 1956, and today’s CRNAs are recognized as specialists in both anesthesia and pain management. The CRNA license is nationally recognized.

“The CRNA role is a fairly standardized role nationally. I could work in any state in any hospital under my license,” says Rowles. In all 50 states, CRNAs have authority to select, prescribe, and administer anesthesia. They also perform preanesthesia as well as intraoperative and postoperative anesthesia care. In some states they can also write prescriptions.

Education and experience required to become a CRNA include at least one year of experience as an RN in an acute care setting; graduate preparation from an accredited nurse anesthesia education program; and passing a national certification examination following graduation.

CRNAs work in any area where anesthesia or pain management services are given, such as the radiology department, OR, and OB. They are also vital in assisting in other areas where venous access and airway management are critical, such as ED, ICU, and in neonatal resuscitation.

CRNAs also provide pain management services in pain management clinics, as part of a private practice, in outpatient settings, as well as in hospitals. The role can include administering such treatments as epidural steroid injections.

Certified Nurse Midwives: Caring for Women Throughout the Lifespan

Certified nurse-midwives (CNM) have historic and educational ties to both nursing and the profession of midwifery. They have been practicing in the U.S. since the 1920s, and today nurse-midwifery practice is legal in all 50 states and the District of Columbia, according to the American College of Nurse Midwives.

CNMs have an especially strong presence in areas of the country where tribal life predominates. In New Mexico 32% to 33% of births are attended by a CNM, and in Alaska they attend 28%.

“We have traditionally cared for vulnerable populations,” says Elaine Germano, RN, DrPH, CNM, FACN, education projects manager for the American College of Nurse-Midwives. CNMs also provide complete primary care for women, as well as prenatal, labor, postpartum, and neonatal care for up to 28 days. Ninety percent of patient visits to CNMs and certified midwives are for primary, preventive care, which includes gynecologic care, according to the American College of Nurse-Midwives. Examples of this kind of care include annual exams and reproductive health visits. Other CNM facts include:

    • Nurse-midwives have prescription-writing authority in all 50 states, the District of Columbia, American Samoa, and Guam.

    • Thirty-three states mandate private insurance reimbursement for nurse-midwifery services, and Medicaid reimbursement is mandatory in all states.

    • CNMs have standardized educational programs. CNMs are RNs who have graduated from a nurse-midwifery education program accredited by the American College of Nurse-Midwives and have passed a national certification examination.

“CNMs are individuals who are educated in two separate professions — nursing and midwifery — and all midwifery educational programs are based on core competencies of midwifery practice,” says Germano.

Catherine Spader, RN, is a freelance writer.