Advanced Practice Registered Nurses, or APRNs, hold both a registered nursing license and a master’s or doctoral degree. APRNs have an expanded scope of practice and may deliver specialized care to patients.
Key Takeaways
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There are four main categories of APRNs: Nurse Practitioner, Certified Nurse Midwife, Clinical Nurse Specialist, and Certified Registered Nurse Anesthetist.
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APRNs are an invaluable resource for patients and healthcare workers. Yet, several institutional challenges continue to weigh on the APRN profession.
The 4 Categories of APRNs
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Nurse Practitioner
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According to the American Association of Nurse Practitioners, NPs can order tests, diagnose, prescribe and oversee treatment plans. During their graduate training, NP students complete tailored training for their specialty of choice (i.e. Pediatrics).
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In 27 states, NPs are required to practice under the supervision of a physician. More on this concept below.
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Certified Nurse Midwife
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CNMs specialize in women’s health, often focusing on pregnancy, delivery and postpartum care. CNMs can also perform routine services such as annual gynecological exams.
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CNMs will not handle or deliver pregnancies with high chances for complications. Instead, CNMs only manage and deliver low-risk pregnancies.
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In 25 states, CNMs can prescribe and practice without physician supervision, so long as they remain within their scope of practice.
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Clinical Nurse Specialist
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A CNS undergoes additional training in a specialized area of focus. CNS’ often work in a hospital or office settings working with certain conditions or populations (i.e. adults with Dementia). Other CNSs may specialize in different areas of healthcare (i.e. healthcare administration or education).
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In 31 states, CNS’ cannot prescribe medication. In 22 states, CNS’ can practice as independent providers.
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Certified Registered Nurse Anesthetist
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Both CRNAs and anesthesiologists administer anesthesia. The main difference is that CRNAs are mid-level providers and anesthesiologists are physicians with either an MD or DO. Another distinction is training requirements, as CRNAs average 2,000 hours of patient hours and anesthesiologists at approximately 12,000 hours.
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In 29 states, CRNAs are granted full practice, while CRNAs licensed in the remaining 21 states must work with a collaborating anesthesiologist.
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ARPNs & the Larger Healthcare Landscape
The Association of Medical Colleges predicts a physician shortage between 54,100 and 139,000 physicians, including shortfalls in both primary and specialty care by 2033. APRNs are critical members of the healthcare system, as they help mitigate staffing shortages and can step in to provide patients with high-quality, accessible and specialized care.
APRNs also play consultative roles by offering opinions that help physicians and other healthcare professionals provide safe and effective patient care.
Challenges in Advanced Practice Nursing
Collaboration Rules
APRNs are considered independent providers if they are permitted to practice without a collaboration agreement. A collaboration agreement is a supervision program in which APRNs are paired with physicians who oversee some or all of their practice.
While collaboration rules vary between APRN categories, let’s use the above CRNA example: certain states allow CRNAs to independently practice without a supervising physician, while others don’t. Challenges for CRNAs subject to collaboration rules include difficulty finding a willing physician, limited autonomy and a need to modify their practice if licensed in multiple states.
Covid-19
In response to anesthesia shortages during the Covid-19 pandemic, the federal government implemented a temporary waiver permitting CRNAs to practice independently. While this was an incredible achievement for CRNAs, it also raises a question – why do some APRN categories receive expansions while state-imposed restrictions limit others? For reference, roughly half of all states limit full practice for both NPs and CNMs.
Trust
Another challenge APRNs face is advocating for professional equality and trust amongst other stakeholders. Since APRNs are trained to perform many services similar to those of physicians, such as diagnosing, prescribing and seeing their own patient caseloads, their work can help alleviate the impact of physician shortages and burnout.
However, some patients may not be familiar with the scope of practice or expertise an APRN has and may not be ready to undergo their care. Some health systems utilize APRN skills to see more patients with more routine and general concerns while reserving those with more chronic or complex problems for physicians.
Tying It Together
Both APRNs and physicians play an enormous role in our healthcare system. In return for their devotion and skill, politicians, healthcare administrators and other healthcare providers must advocate for and support both of these provider types so they can continue to provide excellent care in a collaborative way that prioritizes patients and clinical outcomes.
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Outside the Huddle
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What’s a Nurse Practitioner? | American Association of Nurse Practitioners
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State Practice Environment | American Association of Nurse Practitioners
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Certified Nurse Midwife | Johnson & Johnson Nursing
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State Regulations for CNMs | Midwife Schooling
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What is a CNS? | National Association of Clinical Nurse Specialists
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CNS Scope of Practice and Prescriptive Authority | National Association of Clinical Nurse Specialists
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How calling CRNAs “nurse anesthesiologists” misleads patients | American Medical Association
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CRNA Independent Practice Map | National Council of State Boards of Nursing
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Nurse anesthetists can practice independently amid pandemic, CMS says | Becker’s Hospital Review
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Can I See a Nurse Practitioner Instead of a Doctor? | Cedars-Sinai
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Reviewed by Geetika Rao, MPH | Edited by Nidhi Mahagaokar, MPH | Fact checked by Chris Yang