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Advanced Practice Registered Nurse Roles

Editor: Lorelei D. Punsalan Updated: 3/1/2023 1:45:47 PM


The advanced practice registered nurse (APRN) role has existed for over half a century. APRN role has evolved to provide health care needs to different populations and sub-specialties throughout the United States and its territories. APRNs are registered nurses with master’s and/or doctorate degrees with advanced education and training beyond registered nurses. Therefore, they have additional scopes of practice over and above traditional nursing duties.

A call for APRNs to provide health care to the full extent of their education in the 2010 Institute of Medicine Report on the Future of Nursing rapidly accelerated the production of APRNs. The APRN scopes of practice vary between states because of the rules and regulations governed by the board of nursing at the state level. The National Council of State Boards of Nursing identifies a need to align the APRN scopes of practice with increasing practice mobility for the APRNs to fulfill the increase in access to health care by the public.[1]

Issues of Concern

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Issues of Concern

An APRN is a registered nurse with at least a master's degree in nursing who has completed graduate-level education and training from a nationally accredited program. Training must be based on a specific specialty, such as midwives or anesthesia. It can also be based on a population, such as pediatric or family practice. APRNs must pass a national certification examination that measures the role and specialty-specific or population-focused competencies. Their knowledge and skills are built upon the foundation of nursing to bridge the gap in medical and allied health, providing direct care to patients and focusing on individuals and families.[2] 

These advanced-trained registered nurses are prepared educationally to bear the responsibilities and accountabilities of providing health maintenance and preventive care to the public. License to practice is privileged by the individual state the APRN applies to after receiving a conferred degree from an accredited institution.  

Four APRN roles exist with a license to practice in all US states and territories: 

  • Certified registered nurse anesthetist (CRNA)
  • Certified nurse-midwife (CNM)
  • Clinical nurse specialist (CNS) 
  • Certified nurse practitioner (NP)

Traditionally, surgical doctors trained nurses to provide anesthesia care for surgical patients until the establishment of anesthesiology as a medical specialty in the US.[3] During the Civil War, American surgeons trained nurses to help provide anesthesia care to the thousands wounded in the war. Due to the shortage of anesthetists and the physicians' reluctance to provide anesthetics in remote rural areas, more nurses began to take on this role.[4] The American Association of Nurse Anesthetists (AANA) was founded in 1931, originally as The National Association for Nurse Anesthetists.[3] Nurse anesthetists also practiced anesthesia care in both World War I and World War II.[5]

CRNA credentialing came into existence in 1956.[6] Formal educational programs using simulation, didactics, and full clinical subspecialty rotations are structured to train nurses to provide anesthesia. CRNAs are privileged at the state level to provide anesthesia services, depending on the regulatory stipulation of independent practice or under an anesthesiologist's supervision. Each year, CRNAs have provided anesthesia care to more than 40 million patients in the United States [7].

The practice of midwifery has existed in many cultures on the continents for millennia.[8] Traditionally, women were trained to assist in birthing and caring for the babies and mothers through apprenticeship from experienced older midwives. In remote villages, midwives were often the only skilled providers to exist, providing health care services with great emphasis on physical, emotional, mental, and spiritual care. In the 1800s, male physicians took great interest in exploring childbirth processes, with a focus on the physical aspect of the entire pregnancy's wellbeing. By the turn of the 1900s, many doctors opposed midwife-assisted births, promoting the science of pain relief that hospitals could offer.[8] However, in the Southern states, midwives attended up to 75% of births among the Black communities until the 1940s.

The American Association of Nurse-Midwives (AANM) was founded in 1928, originally known as the Kentucky State Association of Midwives. Certification and credentialing processes began in 1971 after formal educational programs and accreditation were established in the US.[9] Midwife training focuses on a primary commitment to caring for mothers and babies with ancillary services, including annual woman health exams, nutritional counseling, parenting education, and preventive health care. Currently, CNMs are privileged with licenses to independent practice with prescriptive authority in all 50 US states.[10]

Customarily, nurses were trained to work in hospitals to care for unique populations with various healthcare conditions. With the consistency of day-in and day-out caring for patients with similar medical conditions, this line of work enabled the nurses to develop specialized and advanced skills to provide specific healthcare needs to these unique populations. In 1943, the term nurse-clinician was coined by Frances Reiter,  who acknowledged that nurses comfort, teach, protect, encourage, and nurture patients back to health.[11] Since then, the National League for Nursing Education began to advocate for advanced nursing training in universities to prepare nurse clinicians to serve patients with empowerment.

Initially, the CNS specialty was started at a graduate level of the nursing training program, responding to the need to care for patients in psychiatric settings. CNS expansion to other healthcare settings grew rapidly during the 1960s to reciprocate the need to care for complex patients, particularly after the Vietnam War.[11] In 1965, the American Association of Nurses (ANA) proposed in a position statement to allow nurses who received a Master's Degree or higher to claim the role of CNS, emphasizing clinical expertise in selective populations. CNS was not widely adopted to practice with full potential until the 1990s during the health care reform in response to reducing costs and shorter hospital stays.[12] CNS has been providing health care to patients throughout the US, consistently achieving high-quality, cost-effective outcomes with evidence-based practices. Current CNS certification examinations are based on population-specific: Adult/Gerontology, Pediatrics, and Neonatal through the American Nurses Credentialing Center or the American Association of Critical Care Nurses Certification Corporation.[13]

NP role was started in the 1960s by Dr. Loretta Ford, a nurse, and Dr. Henry Silver, a doctor, with a vision to serve the needs of the poor pediatric population in rural Colorado. The role was a disruptive innovation to bridge between a nurse and a doctor. With a strong belief that nurses can provide high-quality primary care to the ailing populations in the remote countryside, the NP role was created to widen healthcare access to the masses. With advanced training and education, nurses can specialize in a population-specific field of study to provide primary care to patients. Looking back in history, nurses were providing primary care to patients independently and autonomously before the rise in regulated medical practices.[14]

In 1965, a formal educational nursing program was first established at the University of Colorado to train nurses on advanced skills to care for patients outside the hospital setting. During the early years of the NP role, NPs were required to work under a physician's supervision with regulatory stipulations, such as prescriptive authority. As the healthcare landscape evolves, particularly after the implementation of the comprehensive healthcare reform Affordable Care Act in 2010 and the Institute of Medicine Report findings on APRN barriers in 2011, NPs are empowered to deliver health care to the extent of their advanced training.[15]

More and more states in the US are granting NPs full authority in rendering health care services. The American Association of Nurse Practitioners (AANP) provides credentialing certification for the

  • Family Nurse Practitioner (FNP),
  • Adult-Gerontology Primary Care Nurse Practitioner (AGPNP), and
  • Emergency Nurse Practitioner (ENP).

The American Nurses Credentialing Center provides certification examinations for the

  • Family Nurse Practitioner (FNP),
  • Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP),
  • Adult-Gerontology Acute Care Nurse Practitioner (AGACNP), and   
  • Psychiatric-Mental Health Nurse Practitioner (PMHNP).

The Pediatric Nursing Certification Board provides certification exams for the

  • Certified Pediatric Nurse Practitioner Primary Care (CPNP-PC) and
  • Certified Pediatric Nurse Practitioner Acute Care (CPNP-AC).

The National Certification Corporation provides credentialing certification exams for the

  • Women's Health Care Nurse Practitioner (WHNP),
  • Obstetrics and Gynecology Nurse Practitioner (OB/GYN NP), and
  • Neonatal Nurse Practitioner (NNP).

APRNs are registered nurses with many clinical hours of nursing experience prior to the start of graduate school. APRNs are educated and trained on specific core competencies in graduate schools.[16] Learning domains include knowledge of practice, person-centered care, population health, scholarship for nursing discipline, quality, safety, interprofessional partnerships, system-based practice, informatics, healthcare technologies, professionalism, and leadership. There are also sub-competencies specific to specialties versus populations.

Different APRN roles have different requirements in clinical training hours and competency-based requirements. In addition, some states have specific regulatory requirements on training topics and clinical hours. Besides the training on the specialty-specific and/or population-specific required competencies, advanced educational programs also prepare APRNs for systems thinking and policy advocacy that empower them to promote changes.[17] Many APRN training programs are moving toward a doctorate level, phasing out the master's level preparation.[18]

APRNs are educated and trained to provide health care utilizing evidence-based practice (EBP). The value and the importance of EBP utilization among APRNs provide guidance for standardizing patient care and ensuring high-quality care at a minimum cost.[19] EBP guidelines for patient care are the standards in APRN training and practice. This facilitates collaborative efforts among allied health professionals. EBP by APRNs promotes autonomy and professional parameters in providing medical care to patients. 

Many states require APRNs to have protocols approved by a medical director to deliver structural plans of care to a specific patient population or specialty based on the APRNs' training. APRNs are employed in various healthcare systems, including outpatient and inpatient environments. However, 26 states in the US have adopted a full practice authority to allow APRNs to practice to the full extent of their education and training without any medical supervision.[20] Full practice authority granted to APRNs has improved access to primary care providers in the health professional shortage areas. This privilege has increased APRN ownership of medical practices as approved by state regulations.[21]

APRNs have advanced training and higher education; hence, autonomy is crucial to allow APRNs to provide medical care to the extent of their training. They are licensed and authorized to (1) evaluate patients, (2) diagnose patient problems, (3) order and interpret diagnostic tests, and (4) initiate and manage treatments, including prescribing medications and controlled substances under the licensure authority of a state board of nursing.[22]

APRNs have been recognized widely at the federal and state levels of medical billing practices.[23] While medical billing and reimbursement is a complex subject, services provided by APRNs are reimbursable at both the state Medicaid and federal Medicare systems.[24] However, third-party payers tend to follow federal rulings on medical service reimbursements.[25] APRNs follow the same rules as other clinicians in billing and reimbursement, such as fees for services or the Merit-based Incentive Payment System. However, a major gap in reimbursement exists in APRNs compared to other practicing clinicians.[26]

Clinical Significance

APRNs play a critical role in providing healthcare access to the public, especially in many rural areas and underserved populations. They utilize their knowledge and skills in nursing to provide holistic plans of care to patients and families, with an emphasis on disease prevention.

APRNs also deliver much-needed healthcare education to laypeople on diverse topics, inclusive of whole-person care. APRNs’ roles are important in the US health care system, continuing to provide increased access and preventive medical care to the public.

Nursing, Allied Health, and Interprofessional Team Interventions

APRNs are part of the interprofessional team providing health care to patients and families, depending on the area of their training. The majority of APRNs in the US are in primary care as nurse practitioners.[21] These advanced trained nurses are forefront healthcare providers, expanding healthcare access, especially in the rural and underserved areas, to the American public. They provide much-needed education in preventive care to patients and families to keep them healthy.

All APRNs are privileged with a license to practice, and most have the autonomy and the authority to furnish medications and therapies in direct patient care. All interprofessional healthcare providers should work closely to ensure safe, quality patient care and provide cost-effective treatments. Barriers should be eliminated to allow APRNs to practice to the extent of their education and training to benefit the patient's care and health costs.[27]

Nursing, Allied Health, and Interprofessional Team Monitoring

The collaboration of APRNs and physicians has been ongoing to provide quality, safe, and cost-effective health care to patients. They are part of the health care team. The addition of APRNs has increased healthcare access to the public. APRNs are registered nurses with advanced education and specialized training to provide health care to patients. They are always malleable to adapt to practice changes and push the boundaries to benefit patients, communities, organizations, systems, society, and humanity.



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