Advanced Practice Nursing

Advanced Practice Nursing Core

All advanced practice nurses perform advanced clinical assessment and most prescribe medications; therefore, all require advanced pathophysiology, advanced physical assessment, and advanced pharmacology. These courses build on principles learned at the undergraduate level.

Advanced Pathophysiology

Advanced Pathophysiology utilizes principles from anatomy and physiology to provide nursing students with an advanced understanding of the pathophysiologic processes underlying human illness and disease entities across the life span, including their associated signs and symptoms and their appropriate laboratory data.

Advanced Clinical Assessment

This course combines lecture and practice to teach students how to obtain histories and perform comprehensive physical examinations on clients throughout the life span. Students practice their skills in the nursing laboratory and in the clinical setting.

Advanced Pharmacology

Advanced Pharmacology focuses on the principles of drug therapy, mechanisms of action, side effects, drug interactions, general concepts in the selection of pharmaceutical agents, as well as prescriptive authority.

Admission Requirements to Advance Practice Master's Programs

Admission requirements to advanced practice master's programs include: licensure as a registered nurse; a bachelor's degree in nursing and official transcripts from an accredited program; GPA of 3.0 or equivalent; and at least one year experience as a registered nurse (must be one year of critical care experience for nurse anesthesia programs).

Nurse Practitioner (NP)

Definition: The American College of Nurse Practitioners (ACNP) defines nurse practitioners (NPs) as registered nurses who have received graduate-level nursing education and clinical training, which enables them to provide a wide range of preventive and acute health care services to individuals of all ages. NPs obtain health histories and perform complete physical examinations; diagnose and treat many common acute and chronic problems; order and interpret laboratory and diagnostic tests; prescribe and manage medications and other therapies; provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed.

Standard of Practice: As with practical and registered nursing, each state defines its own standards for NPs, and these standards vary widely from state to state. An annual NP update called the "Pearson Report" appears in the February issues of The American Journal for Nurse Practitioners. This report supplies NPs with a state-by-state update on laws, rules, regulations, malpractice, and policy issues related to NPs. According to this report, states even differ on NP titles. Alabama and Pennsylvania use Certified Registered Nurse Practitioner (CRNP); Rhode Island and Utah use Registered Nurse Practitioner (RNP); Oregon, Tennessee, and New York use Nurse Practitioner (NP); Ohio and South Dakota use Certified Nurse Practitioner (CNP); California, Connecticut, and Vermont use Advanced Practice Registered Nurse (APRN); and Virginia uses Licensed Nurse Practitioner (LPN). Most states require NP certification to practice; those that don't include New York, North Dakota, and Oregon. And even though the AACN now recommends the DNP, some states (Delaware, Idaho, Indiana, Maryland, Minnesota, and New York, and the District of Columbia) still have no requirement for NPs to have master's degrees. Twenty-two states and the District of Columbia have no requirements for physician involvement for an NP to practice, four require physician involvement but no written protocol, and the remaining states require physician involvement with a written protocol. All states allow NPs to prescribe, but 39 require physician involvement. The abbreviated "Pearson Report" for 2008 can be retrieved at www.acnpweb.org/files/public/2008_Pearson_Report.pdf.

Practice Settings: Most Primary Care Nurse Practitioners (PCNPs) work in physicians' offices, clinics, schools, and occupational health clinics. While some hospital units and emergency centers employ primary care NPs, more of them are utilizing Acute Care Nurse Practitioners (ACNPs), a relatively new NP role. All NPs specialize in a client population. PCNPs specialize in adult, family, pediatric, school, geriatric, and women's health nursing, as well as psychiatric mental health nursing. ACNPs may specialize in a client population, but many opt for a specific nursing area, such as cardiac care, trauma, pulmonology, or oncology.

Scope of Practice: Research demonstrates that Primary Care Nurse Practitioners (PCNPs) deliver competent and cost-effective primary care to clients across the life span. PCNPs perform wellness visit exams (checkups), order and interpret screening tests, administer immunizations, and provide health promotion teaching. They also diagnose and treat people who have acute problems such as ear infections, and chronic ones such as asthma. They prescribe medications and other treatments, see clients back for follow-up visits, and refer clients to specialists when needed. PCNPs perform procedures including suturing, casting, and skin biopsies.

Competencies: The National Organization of Nurse Practitioner Faculties (NONPF) and the AACN developed the Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric and Women's Health. These entry-level competencies are delineated for each specialty area and are intended to be used in conjunction with and build on the core competencies identified for all nurse practitioners. They can be accessed at www.nonpf.com/finalaug2002.pdf.

Practice Setting: Research demonstrates that Acute Care Nurse Practitioners (ACNPs) provide quality care, decrease length of stay, and improve patient and family satisfaction. They assess and manage acutely ill patients within the inpatient/hospital setting, as well as in the emergency department, intensive care unit, specialty labs, acute care wards, specialty clinics, or any combination of these.

Scope of Practice: ACNPs can diagnose and treat medical conditions, and many provide direct client management from admission to discharge, in collaboration with physicians and other members of the healthcare team. Some ACNPs continue to care for clients into the outpatient setting to ensure successful transition after discharge and complete resolution of transitioning their needs. The exact nature and structure of the ACNP role depends on the collaborative agreement with physicians and other members of the healthcare team.

Competencies: The NONPF National Panel for Acute Care Nurse Practitioner Competencies developed the Acute Care Nurse Practitioner Competencies. These entry-level competencies are intended to be used in conjunction with and build on the core competencies identified for all nurse practitioners. This document may be accessed at www.aacn.nche.edu/ Education/pdf/ACNPcompsfinal2004.pdf.

Many states require that NPs be certified in their specialty area. To attain certification, NPs must have graduated from an accredited graduate-level nurse practitioner program, successfully pass a certification exam to verify knowledge in their specialty, and pay a fee. NPs are expected to maintain their certification by demonstrating continued competency in their specialty through clinical practice, continuing nursing education, completing academic courses, completing self-assessment modules, publishing in peer-reviewed journals, presenting at nursing conferences, and/or taking another exam. Agencies that certify nurse practitioners are:

• The American Nurses Credentialing Center certifies family, adult, pediatric, school nurse, acute care, diabetes management, adult psychiatric mental health, and family psychiatric mental health nurse practitioners.
• The Pediatric Nursing Certification Board certifies pediatric primary care nurse practitioners and pediatric acute care nurse practitioners.
• The American Academy of Nurse Practitioners certifies family, adult, and gerontological nurse practitioners.

Clinical Nurse Specialist

Definition: The National Association of Clinical Nurse Specialists defines Clinical Nurse Specialists (CNS) as expert clinicians in a specialized area of nursing practice that may be a population (such as children or older adults), a setting (such as dialysis or critical care), a disease or subspecialty (such as HIV/AIDS or orthopedics), a care type (such as palliative care or rehabilitation), or a specific problem (such as pain or cardiac rehabilitation). All CNSs focus on five areas: clinical practice, teaching, research, consulting, and management.

CNSs are also prepared as case managers who organize and coordinate client services and resources, controlling costs in the interim. Therefore, they are invaluable in managed care. Their educational role covers patient, nursing, and other staff education, as well as community education, and the teaching and precepting of nursing students.

The role of the CNS is not without controversy due to its similarities with the NP role and more recently that of the clinical nurse leader. In 1994 AACN held a conference on role differentiation to decide whether the two roles should remain separate or be blended. The reasons for blending the roles were: less confusion for the public; clarification of titles and competencies; increased political and professional power; greater marketability; guaranteeing that advanced practice nurses would be prepared at the master's level; and increased benefits to clients. Sixty-eight percent of the group voted to merge the two roles, and schools began the process. But as you can see here, the merger never happened.

In 2006, AACN issued a statement noting its support of the CNS role. Citing its awareness of the direct link between graduate-prepared nurses and both patient safety and positive outcomes, AACN supported the definition of the CNS as outlined by the American Nurses Association's 2004 Nursing: Scope and Standards of Practice and stated that CNSs play a unique role in the delivery of high-quality nursing care. CNSs are experts in evidence-based nursing and practice in a range of specialty areas. In addition to direct patient care, they teach, mentor, consult, research, manage and improve systems, and are adept at adapting their practice across settings. CNSs provide expert consultation to all care providers and implement improvements in healthcare delivery systems. AACN recognized the growing body of evidence that shows a strong correlation between CNS interventions and safe, cost-effective patient care. CNSs reduce hospital costs and lengths of stay, reduce frequency of emergency room visits, improve pain management practices, increase patient satisfaction with nursing care, and minimize complications in hospitalized patients. Thus, AACN encourages hospitals and other healthcare providers to use CNSs and engage them in the health arena. AACN further stated that CNSs do not duplicate the role of Clinical Nurse Leaders, who are educated as generalists, while CNSs are educated as specialists.

Standards of Practice: State nurse practice acts govern standards of practice for clinical nurse specialists. Since some CNSs prescribe medications, their standards are similar to nurse practitioners, thus some states require physician involvement, while others do not. States also accept and incorporate the standards of the National Association of Clinical Nurse Specialists (NACNS) Statement on CNS Practice and Education, and the AACN Essentials of Masters Education for Advanced Practice.

Practice Settings: While many CNSs practice in hospitals, others practice in a variety of settings. Additional settings include long-term care, cancer treatment centers, renal dialysis centers, and rehabilitation facilities.

Scope of Practice: CNS practice focuses on five areas: clinical practice, teaching, research, consulting, and management. As experts in clinical practice, CNSs work with other healthcare professionals to improve client care. They assess and intervene with complex health problems within their specialty area, using appropriate technology, products, and devices. CNSs educate other staff and precept nursing students. They use research to create evidence-based practice, and perform consultative functions in multiple health settings. As leaders, they act as change agents by developing healthcare standards, assisting in the implementation of standards, facilitating goal setting and achievement, and evaluating outcomes. CNSs also serve as leaders in the community to better overall health care.

Competencies: The National Association of Clinical Nurse Specialists (NACNS) determined required competencies in their document, the NACNS Statement on CNS Practice and Education. This statement defines CNS practice competencies and makes recommendations for CNS education, and is available at www.nacns.org/statement.shtml.

Certification: CNSs can obtain certification by examination in some, but not all, specialties. ANCC offers credentialing for CNSs in the following specialties: adult health, pediatric, child and adolescent psychiatric and mental health, adult psychiatric and mental health, diabetes management, gerontological, home health, and public and community health. ANCC and NACNS are presently addressing a barrier to practice faced by a number of CNSs, the lack of a certification exam in many specialties. State boards of nursing often require national certification for practice. Since certification is available for a limited number of specialties, ANCC, working in collaboration with NACNS, is developing a CNS core certification examination that will test the competencies required of all CNSs regardless of their specialty. ANCC expects this exam to be available in September 2009.

Some specialty nursing organizations offer certification for CNSs. The Oncology Nursing Certification Corporation (www.oncc.org) offers Oncology CNS certification. The American Association of Critical Care Nurses Certification Corporation (www.certcorp.org) offers the Critical Care Nurse Specialist certification, and the Orthopaedic Nurses Certification Board (www.oncb.org) offers Orthopedic CNS certification.

Psychiatric Nurse Practitioners and Clinical Specialists

Advanced practice psychiatric nurses provide comprehensive mental health care to individuals, groups, and families across the life span. An advanced practice psychiatric nurse may function as a clinical nurse specialist, nurse practitioner, or, in some cases, both, since they are very similar in this specialty area. As previously noted, Psychiatric Mental Health Clinical Nurse Specialists (PMHCNS) were the first advanced practice nurses in the United States. Their role today consists of five domains: research, clinical leadership, education, consultation, and expert clinical practice, but their practice emphasis may vary. The scope of practice for PMHCNSs can include psychotherapy practice as well as staff development.

Psychiatric Mental Health Nurse Practitioners (PMHNPs) primarily practice in a clinical setting, diagnosing psychiatric disorders and utilizing a range of interventions that include medications, individual therapy, family therapy, group therapy, and behavioral therapy. Both clinical nurse specialists and nurse practitioners practice with a defined patient population (such as adults, elders, or children and adolescents) or a specific problem, such as eating disorders or substance abuse, and both work in a variety of settings, including: inpatient psychiatric units, emergent or urgent psychiatric centers, outpatient services, private practices, and psychiatric consultation liaison services (with medically ill clients). They may also work as specialists in settings such as jail health services, high-risk pregnancy clinics, schools, substance abuse centers, and recovery programs.

NONPF's National Panel for Psychiatric-Mental Health NP Competencies developed the Psychiatric Mental-Health Nurse Competencies, a document that emphasizes the unique philosophy of practice for the psychiatric-mental health nurse practitioner specialty and the needs of the populations served. These entry-level competencies apply to all Psychiatric Mental Health NPs regardless of the population they serve and are intended to be used in conjunction with and build on the core competencies identified for all nurse practitioners. This document can be accessed at www.aacn.nche.edu/Accreditation/ psychiatricmentalhealthnursepractitionercopetencies/FINAL03.pdf.

Nurse Midwife

Definition: According to the American College of Nurse Midwives, nurse midwives are advanced practice nurses with additional training to deliver babies and provide prenatal and postpartum care to women. Nurse midwives are so involved in labor and delivery that they sometimes do not leave the mother during the entire labor process. They are trained to recognize signs of complications and will consult with a physician to become involved in the delivery if needed. Nurse midwives qualify to administer medications and perform procedures; however, they use these only when requested by the mother.

Nurse midwives differ from lay midwives, who are now known as direct-entry midwives. Nurse midwives are registered nurses with advanced practice education. While some direct-entry midwives may be nurses, they are not advanced practice nurses. Direct-entry midwives are independent practitioners educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. They are trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle, primarily in out-of-hospital settings. The American College of Nurse Midwives offers Certified Midwife (CM) designation for lay midwives who graduate from a midwifery school accredited by the ACNM, and pass a certification exam.

To become a certified nurse midwife (CNM) you must graduate from a nurse midwifery program accredited by the American College of Nurse Midwives, and pass a national certification exam. CNMs can practice anywhere in the United States. Some states require national certification for licensed CNMs to practice midwifery. Don't rule out this specialty if you're male; approximately 2 percent of CNMs are men.

Standards of Practice: Each state sets its own standards for the practice and regulation of nurse midwifery. Prescriptive authority is an issue, as it is for other advanced practice nurses, with the addition of intrapartum prescriptive and administrative authority. The ACNM provides fact sheets for each state at www.acnm.org/state_legislation.cfm. These individual fact sheets outline practice and reimbursement, as well as statistics, education, and an overview of nurse midwives.

Practice Settings: Nurse midwives practice in homes, birth centers, hospitals, private practice, state and county health departments, and charitable organizations.

Scope of Practice: Nurse midwives provide prenatal care, birthing, postpartum care, gynecologic exams, treatment of sexually transmitted diseases, birth control, and contraception (birth control), which includes injections, implants, intrauterine devices (IUDs), birth control pills, and diaphragms. Nurse midwives provide primary healthcare to women from menarche through menopause and beyond, as well as health teaching on issues including natural childbirth, teen pregnancy, and breast-feeding.

Competencies: The Core Competencies for Basic Midwifery Practice describes the fundamental knowledge, skills, and behaviors expected of a new practitioner. They may be accessed at www.midwife.org/display.cfm?id=484.

Certification: The American Midwifery Certification Board (AMCB), formerly the ACNM Certification Council, Inc. (ACC) is the national certifying body for Certified Nurse-Midwives (CNMs). They can be accessed at www.amcbmidwife.org.

Nursing Notes

A Lesson on Nurse Midwifery, by Nicole Rouhana

Nurse midwifery is a privilege that allows me to participate in the most intimate aspects of health and reproduction a woman experiences. This glimpse into the most private recesses of a women's soul allows me to be with women whether they are profoundly happy or terribly sad. I have had women call me after the death of a loved one, just to share the news with somebody they had a connection with despite the fact it had nothing to do with their healthcare. Sometimes we care for women who do not share our same values or lifestyles but we still support, educate respectfully, and help them to make the best decisions they can regarding their reproductive health.

But what does it actually mean to be a nurse midwife? It means long hours that require a huge commitment, missing important family events and holidays, missing regular hours of sleep on a routine basis, and a call schedule that can sometimes interfere with life in general. It means caring for women living on the fringes of society, struggling to make ends meet and doing the best they can for themselves and their family, often forgotten or overlooked by society. It means hearing stories of abuse, shared for the first time, as nobody else had ever bothered to ask. Conversely, it also means being with a mother when she hears her baby's heart for the first time, helping a new mother nurse her baby for the first time after a long labor, and watching as a new family emerges from the shadows of a semilit labor room, or witnessing the profound empowerment that develops in a woman who has been an active participant at her birth and realizes that she alone could do this for her baby. Midwifery for me is a true work of art grounded in science.

Some of the most memorable lessons I have learned in nurse midwifery practice have come from some of the poorest, most disenfranchised women I have cared for. These lessons were not intentional, but rather were examples of fortitude and perseverance they showed me. One such memory involved a young woman named Phyllis. She had an infant who was born with a disability that would not be cured or improved, but rather worsened over time. She had recently relocated to my area from the Midwest and found herself pregnant for a second time. The young father of the baby had grown weary of responsibility and was no longer in the picture. Because she had a limited support system, she and I developed a relationship over her 40 weeks of prenatal care. As the child had grown too big to physically carry, she wheeled him around, bringing him to each prenatal visit. During her labor, we received a phone call from the neighbor caring for her child at home. The child had begun seizing, which was somewhat routine, and was taken to the emergency room at the same hospital. As the labor progressed, the child's seizures continued, beyond what they had ever been before. After a few hours a neurologist was called in who recommended anesthesia to control the seizures. The risk associated with this treatment was that the child might not resume consciousness and the seizures could no longer be controlled medically. Phyllis and I discussed this in between contractions and she consented. The labor continued and within the next few hours she delivered a health baby girl uneventfully. At six hours post partum Phyllis and I went to the ICU to visit her son, who continued to seize under anesthesia. A storm raged outside on this hot summer night and I stood at the window and watched the silent bolts of lightning flash in heavy humid air, listening to the cardiac monitor regularly beeping behind the curtain as Phyllis crooned comforting words to her son. "Mommy is here, Kenny. Guess what? We have a new baby sister and she is healthy and beautiful. It's okay to go now … she's here, Mommy is okay, now you rest and go to sleep." Within half an hour the cardiac monitor began to sound irregular beats, pausing for longer intervals, as Kenny's heart began to fail. The storm raged on as Phyllis continued quietly talking. By 2 A.M. we sat and held her son's lifeless body, finally at peace and seizure-free. His journey had come to an end. A soft and gentle quiet rain had moved in after the storm as the outside temperature dropped. I will always remember the intrinsic connection that night between mother and son. I am grateful that I was privileged to have been part of that process.

Nurse Anesthetist

Definition: The American Association of Nurse Anesthetists (AANA) define nurse anesthetists (also known as certified registered nurse anesthetists or CRNAs) as anesthesia professionals who safely administer approximately 30 million anesthetics to clients each year. The credential of CRNA first existed in 1956, and research indicates that nurse anesthetists provide the same quality of care as that provided by their physician counterparts. Regardless of whether they are physicians or nurses, all anesthesia professionals give anesthesia the same way.

Nurse anesthesia is a popular advanced practice role because of its independence and salary. It is also a popular choice of male nurses. Approximately 44 percent of all nurse anesthetists and student nurse anesthetists are men, compared with less than 10 percent in the nursing profession as a whole.

Standards of Practice: The AANA Scope and Standards of Practice acts as a guide for nurse anesthetists and healthcare providers regarding nurse anesthetist practice (www.aana.com/uploadedFiles/Resources/Practice_Documents/scope_stds_nap07_2007.pdf). As with other areas of nursing, state nurse practice acts guide and regulate the practice of nurse anesthetists. Some nurse practice acts specifically limit the administration of anesthetics to nurse anesthetists. State summaries are found at www.aana.com/Resources.aspx?ucNavMenu_TSMenuTargetID=52&ucNavMenu_TSMenuTarget Type=4&ucNavMenu_TSMenuID=6&id=798.

Practice Settings: Nurse anesthetists provide anesthesia in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other qualified healthcare professionals. Nurse anesthetists practice in every setting where anesthesia is delivered: hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, plastic surgeons, and pain management specialists; and the U.S. military, Public Health Services, and Department of Veterans Affairs healthcare facilities. Nurse anesthetists have been the main providers of anesthesia care to U.S. military men and women on the front lines from World War I through the conflict in Iraq, but they first provided anesthesia to wounded soldiers during the Civil War.

Nurse anesthetists are the primary anesthesia providers in rural areas, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical, and trauma stabilization services to their local communities. In some states, nurse anesthetists are the only anesthesia providers in nearly 100 percent of the rural hospitals.

Scope of Practice: Nurse anesthetists care for clients' anesthesia needs before, during, and after surgery or the delivery of a baby. They perform physical assessments and participate in preoperative teaching. Nurse anesthetists prepare for anesthetic management, administer anesthesia to keep clients pain-free, and maintain anesthesia intraoperatively. They also oversee clients' recovery from anesthesia and follow the client's postoperative course from recovery room to the client care unit.

Competencies: AANA has already mobilized and created a doctoral level competency document for nurse anesthetists. This may be accessed at www.aana.com/uploadedFiles/Professional_Development/Nurse_Anesthesia_Education/Educational_Resources/DTF_Report/competencies.pdf.

Certification: The National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA) certifies nurse anesthetists as CRNAs, while the Council on Certification of Nurse Anesthetists oversees recertification.