Advanced Nursing Practice

I would like to explore the different fields of Advanced Nursing Practice.

The four that I will address are the Nurse Anesthetist, the Clinical Nurse Specialist, the Nurse Practitioner and the Nurse Mid-wife.

Advanced Practice Nurses are Registered Nurses with specialty training at the master’s-degree level, in primary care settings, such as the Nurse Practitioners and Nurse Midwives and acute care of inpatients, such as the Clinical Nurse Specialists and in operating rooms, such as Nurse Anesthetists. This has opened a door in the nursing field. Nurses’ roles are no longer limited. Nurses now have opportunities to advance their career and expand their roles. Advanced Practice Nurses can be more directly involved in patient care decisions and be more independent from the physician. Advanced Practice Nurses are respected role models for Registered Nurses.

What are Advanced Practice Nurses?

As defined by the American Nurses’ Association Congress of Nursing Practice:

Nurses in advanced clinical nursing practice have a graduate degree in nursing. They conduct comprehensive health assessments and demonstrate a high level of autonomy and expert skill in the diagnosis and treatment of complex responses of individuals, families and communities to actual or potential health problems. They formulate clinical decisions to manage acute and chronic illness and promote wellness. Nurses in advanced clinical practice integrate education, research, management, leadership, and consultation into their clinical role. They function in collegial relationships with nursing peers, physicians, professionals, and others who influence the health environment. (McLoughlin 1992).

Roles in Nurse Midwifery and Nurse Anesthesia developed in the first half of the 20th century, while the Certified Nurse Specialist and the Nurse Practitioner roles developed in the second half of the century. There were many elements that created the demand for Advanced Practice Nurses. The large number of immigrants in the early 1900s created the need for Nurse Midwives. Another thing that influenced the growth of Nurse Midwives was when the government started to become aware of the poor maternal and child health in the US when it didn’t have enough healthy males to serve in the armed forces in WWI. (Komnenich 1998). Physicians also had a lack of interest in obstetrics and this increased the opportunity for nurses to fill the role of Nurse Midwife (Komnenich 1998).

Physician shortages in the 1960s created the need for clinical specialization in nursing in the form of Certified Nurse Specialists and Nurse Practitioners (Ford 1995; Komnenich 1998). Overall poor health care, especially for children, led to the development of the first Nurse Practitioner program at the University of Colorado in 1965 (Ford 1995). The practice of Nurse Practitioners has been constantly evolving since 1965, when the role was developed by Henry Silver, M.D., and Loretta Ford, R.N. (Sox 1979). Consumers liked the humanistic, health-promoting and cost-effective services that the Nurse Practitioner and the Nurse Midwife provided and this consumer demand and preference led to the expansion of these roles. This was a simple concept of supply and demand.

Nurse Anesthetists owe the biggeat part of their development to the wars (Bigbee 1996). Also, in the early 1900s physicians became more interested in surgery than in anesthesia and this provided the opportunity for nurses to move into this field (Bigbee 1996).

Government and agency funding and support have financed the developed of new programs to educate and prepare nurses in the Advanced Practice roles. “There are now approximately 100,000 Advanced-Practice Nurses, half of them Nurse Practitioners and Nurse Midwives, and half Clinical Nurse Specialists” (Nursing Facts, 1993). Although they are similar to the physician in making primary care decisions, Nurse Practitioners bring additional benefits to their practice. “Nurses are more likely to talk with patients and adapt medical regimens to a patient’s preferences, family situation, and environment” (Bessman, 1974). “They are also more likely to provide disease-prevention counseling, health education, and health-promotion activities, as well as to know about and use community resources, such as nutrition programs, self-help or group therapy, and parenting and stress-reduction programs” (Mandelblatt 1993). Clinical Nurse Specialists are also proving that high-quality, cost-effective care can be given in place of medical care of inpatients who are stable (Knickman 1992).

The role of Advanced Practice Nursing continues to change and develop. In the past few years, state legislatures authorized Nurse Practitioners to receive direct payment and write prescriptions. These changes have increased the Nurse Practitioner’s independence. This has resulted in Nurse Practitioners establishing independent practices that provide the same health care of primary care physicians, or they can also work in practices where the Nurse Practitioner and the doctor care for patients together (Spitzer 1974). “Many states are increasing the level of authority and reimbursement for Nurse Practitioners. Most private insurance companies and health maintenance organizations cover the services of Nurse Practitioners (Pearson 1993). Some blame the nursing shortage partly on Advanced Practice Fields. Registered Nurses are obtaining their master’s degree in order to earn more money and have more opportunities.

A conceptual framework for advanced practice: The skills and knowledge base of consultancy, underpinned by a strong nursing foundation, augmented by strong leadership and combined with the educator and researcher functions, are presented as the attributes of the advanced practitioner/ consultant nurse (Manley, 1996).

What is a Nurse Anesthetist?

Nurse Anesthetists work in hospital operating rooms, emergency rooms, dental offices, and outpatient settings. They work under an Anesthesiologist or MD. They sedate patients for surgery and/or procedures. The Nurse Anesthetist must be a registered nurse with either a BSN or a bachelor’s degree in a biophysical science, and then complete a minimum of 24 month training courses in anesthesiology from an approved school of nurse anesthesia. Training is usually through a graduate school and leads to a master’s degree. Course work includes anesthesia practice, pharmacology, respiratory care, anatomy and physiology. After completing the training, you must pass the exam by the Council on Certification for Nurse Anesthetists to become a Certified Registered Nurse Anesthetist.

Requirements to be accepted into a Nurse Anesthetist’s program are the following:

A minimum of one year of recent nursing experience, as a registered nurse with a basic Baccalaureate degree in nursing, in an acute care patient setting. Highest priority is given to applicants who have the most recent work in a large hospital ICU or CCU settings where the applicant is likely to have a broad base of invasive hemodynamic monitoring experience, and administering vasoactive drugs in the care of adult patients. Applicants will be considered who work in recovery rooms where patients routinely have invasive hemodynamic monitors. Emergency room experience will be considered only if the candidate can demonstrate he/she cares for patients with invasive monitors in this setting.

A class in physical assessment must be completed within the past five years. Students graduating from a BSN program within the past five years have had this included in their program. Graduates from a BSN program longer than five years ago and graduates from a baccalaureate degree in an area other than nursing, must supply documentation of completing a specific course in physical assessment.

There is a minimum 3.0 cumulative GPA (including minimum 3.0 GPA in science areas.) Candidates may be offered an interview if their scores have been borderline in early years but whose recent transcript shows evidence of strong science grades.

*After graduation, licensure and certification, a Nurse Anesthetist’s average salary is $70,000- $100,000 per year. (www.allnursingschools.com)

What is a Clinical Nurse Specialist?

Clinical Nurse Specialists is a licensed registered nurses who have graduate preparation (Master’s or Doctorate) in nursing as a Clinical Nurse Specialist. Clinical Nurse Specialists are expert clinicians in a specialized area of nursing practice.

Clinical Nurse Specialists practice in a wide variety of health care settings. In addition to providing direct patient care, Clinical Nurse Specialists influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems. Clinical Nurse Specialist’s practice integrates nursing practice, which focuses on assisting patients in the prevention or resolution of illness, with medical diagnosis and treatment of disease, injury and disability.

Applicants to the MSN program must meet these general requirements for admission to graduate studies. The applicant must possess a baccalaureate degree in nursing from a nationally accredited program and have current licensure as a registered nurse. The applicant must have two years of employment as a registered nurse in a clinical setting. Successful completion of health assessment, statistics, and research courses within the last 10 years with a minimum GPA of 3.0 is required. Clinical references and interview may be required. * After graduation, licensure and certification, the average salary for a Clinical Nurse Specialist is $65,000-$78,000 per year. (www.allnursingschools.com)

What is a Nurse Practitioner?

A Nurse Practitioner is a Registered Nurse who has completed advanced education and training in the diagnosis, management and treatment of common medical conditions and chronic illnesses. Nurse Practitioners provide a broad range of health care services. They provide some of the same care provided by physicians and a Nurse Practitioner can serve as a patient’s regular health care provider. Nurse Practitioners see patients of all ages. Nurse Practitioners focus on patients’ conditions as well as the effects of illness on the lives of the patients and their families. Nurse Practitioners provide prevention plans, wellness teaching, and patient education. In addition to health care services, Nurse Practitioners conduct research and are often active in patient advocacy activities.

Nurse Practitioners practice in all states, but because the profession is state regulated, care provided by Nurse Practitioners varies. Most Nurse Practitioners specialize in a particular field of medical care, and there are as many types of Nurse Practitioners as there are medical specialties. Nurse Practitioners provide high-quality, cost-effective individualized care that is comparable to the health care provided by physicians, and Nurse Practitioner services are often covered by insurance providers.

To be licensed as a Nurse Practitioner, the candidate must first complete the education and training necessary to be a Registered Nurse. The BSN is a minimal requirement for Nurse Practitioners. The candidate must complete a state-approved program that usually specializes in a field such as family practice, internal medicine, or women’s health. After completing the education program, the candidate must be licensed by the state in which he or she plans to practice. The State Boards of Nursing regulate Nurse Practitioners and each state has its own licensing and certification criteria. Nurse Practitioners may have to get certification by the American Nurses Credentialing Center (ANCC) or a specialty nursing organization. After receiving state licensing, a Nurse Practitioner can apply for national certification from the ANA or other professional nursing boards such as the American Academy of Nurse Practitioners (AANP).

*After graduation, licensure and certification the average salary for a Nurse Practitioner is $65,000- $78,000 per year. (www.allnursingschools.com)

What is a Nurse Midwife?

The word midwife has been used for centuries to describe a woman who is “with women” at birth. A midwife was traditionally an older female in the family or the community. Today, the word indicates care that focuses on the specific needs of women and the individuals who hold the title are highly educated professionals who work with physicians.

Today’s Certified Nurse Midwife is a skilled healthcare professional who provides primary healthcare to women. Certified Nurse Midwives emphasize health promotion, education, and disease prevention. Certified Nurse Midwife provides contraceptive counseling, family planning, care during pregnancy and childbirth and normal gynecological services. Certified Nurse Midwives and Certified Midwives can share their professional healthcare abilities by teaching at a university in schools of nursing, public health, medicine, and allied health. Certified Nurse Midwives and Certified Midwives can conduct clinical research on such key topics as the safety, health benefits and cost-effectiveness of non-medical and medical interventions; maternal and infant healthcare; HIV/AIDS; new contraceptive methods; breast-feeding; and gynecological care. Certified Nurse Midwives and Certified Midwives can become active in local and national legislative affairs and be a policy maker for health care reform.

Certified Nurse Midwives and Certified Midwives must graduate from an accredited education program and pass a certification exam. Because of the high standards established for education and certification, Certified Nurse Midwives are licensed in all 50 states and the District of Columbia. They are held to the standards of practice set by the American College of Nurse Midwives and by state licensing organizations.

Certified Nurse Midwives and Certified Midwives will have the authority in most states to write prescriptions for many of the medications and health care products needed in their practice. Certified Nurse Midwives and Certified Midwives can play a key role in reducing the maternal and infant death rate both in this country and around the world.

*After graduation, licensure and certification, the average salary for a Nurse Midwife is $72,000- $85,000 per year. (www.allnursingschools.com)

In conclusion, nurses have more choices than ever before. “There is reason to believe that our successes will continue and that our problems can be solved. Nursing is a profession where exciting things are happening and where the best is yet to come” (Creasia p.42).

References for Nursing Concepts:

http://audriejones.tripod.com/advancednursingeducation

Bessman AN. Comparison of medical care in nurse clinician and physician clinics in medical school affiliated hospitals. J Chronic Dis 1974;27:115-125.

Bigbee, J.L. (1996) History and Evolution of Advanced Nursing Practice. In Advanced Nursing Practice: an Integrative Approach. W.B. Saunders, Philadelphia, pp. 3-24.

Creasia, J.L., Parker, B. Conceptual Foundations: The Bridge to Professional Nursing Practice, 3rd Edition. St. Louis: Mosby Inc., 2001.

Ford, L.C. (1995) Nurse Practitioners. Myths and Misconceptions. Journal of the New York State Nurses Association, 26 (7), 69-74.

Knickman JR, Lipkin M Jr, Finkler SA, Thompson WG, Kiel J. The potential for using non-physicians to compensate for the reduced availability of residents. Acad Med 1992;67:429-438.

Komnenich, P. (1998) The Evolution of Advanced Practice in Nursing. In Advanced Practice Nursing: Emphasizing Common Roles. FA Davis Company, Philadelphia, pp. 8-46.

Mandelblatt J, Traxler M, Lakin P, et al. A nurse practitioner intervention to increase breast and cervical cancer screening for poor, elderly black women. J Gen Intern Med 1993;8:173-178.

Manley, K. (1997) A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/ consultant nurse
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Nursing facts: advanced practice nursing: a new age in health care. Washington, D.C.: American Nurses’ Association, 1993. (PR-11).

Pearson LJ. 1992-93 Update: how each state stands on legislative issues affecting advanced nursing practice. Nurse Pract 1993;18:23-38.

Sox HC Jr. Quality of patient care by nurse practitioners and physician’s assistants: a ten-year perspective. Ann Intern Med 1979;91:459-468.

Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington Randomized Trial of the Nurse Practitioner. N Engl J Med 1974;290:251-256.