Advanced Practice Registered Nurse Roles

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 midwifery or anesthesia. It can also be based on a population, such as pediatric or family practice. APRNs must pass a national certification examination that assesses role-specific and specialty- or population-focused competencies. Their knowledge and skills are built on a nursing foundation, bridging the gap between medicine and allied health, providing direct patient care, 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 granted by the individual state to which the APRN applies 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

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 an anesthetist shortage and physicians' reluctance to provide anesthesia in remote rural areas, more nurses began taking 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 was established in 1956.[6] Formal educational programs using simulation, didactics, and full clinical subspecialty rotations are structured to train nurses to provide anesthesia. CRNAs are authorized at the state level to provide anesthesia services, either independently 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 across many cultures for millennia.[8] Traditionally, women were trained to assist in childbirth and in caring for mothers and babies through apprenticeship with experienced older midwives. In remote villages, midwives were often the only skilled providers, offering healthcare services with a strong emphasis on physical, emotional, mental, and spiritual care. In the 1800s, male physicians took a keen interest in childbirth, focusing on the physical aspects of pregnancy and its outcomes. 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 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 centers on a primary commitment to caring for mothers and babies, with ancillary services including annual women's health exams, nutritional counseling, parenting education, and preventive healthcare. Currently, CNMs are licensed to practice independently with prescriptive authority in all 50 US states.[10]

Historically, nurses were trained to work in hospitals to care for specific populations with diverse healthcare conditions. Through day-in, day-out care for patients with similar medical conditions, this line of work enabled nurses to develop specialized, advanced skills to meet the specific healthcare needs of 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 has advocated for advanced nursing training at universities to prepare nurse clinicians to serve patients with greater empowerment.

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

The nurse practitioner role began in the 1960s with Dr. Loretta Ford, a nurse, and Dr. Henry Silver, a physician, who envisioned serving the needs of low-income pediatric patients in rural Colorado. The role was a disruptive innovation that bridged the gap between nurses and doctors. With a strong belief that nurses can provide high-quality primary care to underserved populations in remote areas, the nurse practitioner role was created to expand access to healthcare. With advanced training and education, nurses can specialize in a population-specific field to provide primary care. Historically, nurses provided primary care to patients independently and autonomously before the rise of regulated medical practice.[14]

In 1965, a formal educational nursing program was established at the University of Colorado to train nurses in advanced skills for caring for patients outside the hospital setting. In the early years of the nurse practitioner role, nurse practitioners were required to work under a physician's supervision, with regulatory stipulations such as prescriptive authority. As the healthcare landscape evolves, particularly following the implementation of the Affordable Care Act (ACA) in 2010 and the Institute of Medicine report on barriers to APRN practice in 2011, nurse practitioners are increasingly empowered to deliver care commensurate with their advanced training.[15]

More and more states in the US are granting nurse practitioners full authority in rendering healthcare services. The American Association of Nurse Practitioners (AANP) provides certification for the

• Family Nurse Practitioner (FNP)
• Adult-Gerontology Primary Care Nurse Practitioner (AGPNP)
• 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)
• Psychiatric-Mental Health Nurse Practitioner (PMHNP)

The Pediatric Nursing Certification Board provides certification exams for the

• Certified Pediatric Nurse Practitioner Primary Care (CPNP-PC)
• 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 nurse practitioner)
• Neonatal Nurse Practitioner (NNP)

APRNs are registered nurses with many clinical hours of nursing experience before 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 in the nursing discipline, quality and 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. In addition to training in specialty- and/or population-specific required competencies, advanced educational programs prepare APRNs for systems thinking and policy advocacy, empowering them to effect change.[17] Many APRN training programs are moving toward a doctoral level, phasing out master's-level preparation.[18]

APRNs are educated and trained to provide healthcare utilizing evidence-based practice (EBP). The value and importance of EBP utilization among APRNs guide the standardization of patient care and help ensure high-quality care at minimal 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 standards in patient care. 

Many states require APRNs to have protocols approved by a medical director to deliver structured plans of care for specific patient populations or specialties, consistent with their training. APRNs are employed across various healthcare settings, including outpatient and inpatient care. However, 26 states in the US have adopted full practice authority, allowing APRNs to practice to the full extent of their education and training without 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; therefore, autonomy is crucial to enable them to provide medical care commensurate with their training. They are licensed and authorized to evaluate patients, diagnose patient problems, order and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications and controlled substances under the licensure authority of a state board of nursing.[22]

APRNs have been widely recognized at the federal and state levels of medical billing practices.[23] While medical billing and reimbursement are complex, services provided by APRNs are reimbursable under both state Medicaid and federal Medicare programs.[24] However, third-party payers typically follow federal rulings on medical service reimbursement.[25] APRNs follow the same rules as other clinicians for billing and reimbursement, including fee-for-service and the Merit-based Incentive Payment System. However, a significant reimbursement gap exists for APRNs compared to other practicing clinicians.[26]

Clinical Significance

APRNs play a critical role in expanding access to healthcare, especially in rural areas and underserved populations. They apply their nursing knowledge and skills to develop holistic care plans for patients and families, with an emphasis on disease prevention.

APRNs also deliver much-needed healthcare education to laypeople on a range of topics, including whole-person care. APRNs’ roles are important in the US healthcare system, continuing to expand access to preventive care for the public.

Nursing, Allied Health, and Interprofessional Team Interventions

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

All APRNs are licensed to practice, and most have the autonomy and authority to prescribe medications and therapies in direct patient care. All interprofessional healthcare providers should work closely together to ensure safe, high-quality patient care and deliver cost-effective treatments. Barriers should be eliminated to enable APRNs to practice to the extent of their education and training, benefiting patient care and reducing healthcare 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 healthcare to patients. They are part of the healthcare team. The addition of APRNs has expanded public access to healthcare. APRNs are registered nurses with advanced education and specialized training to provide patient care. They are always malleable, adapting to practice changes and pushing the boundaries to benefit patients, communities, organizations, systems, society, and humanity.