Advanced Practice Nurses

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Advanced practice nurses


Advanced practice nurses are typically those nurses prepared at the master's or doctoral level, and they fall into four categories of clinicians: clinical nurse specialists, certified registered nurse anesthetists, nurse practitioners, and certified nurse-midwives.


Clinical nurse specialists

Clinical nurse specialists (CNSs) are licensed registered nurses (RNs) with additional master's or doctorate-level training in CNS. These advanced practice nurses are clinical experts in theory-based or research-based nursing, focusing on specific specialty areas.

CNSs have broadened patient care roles because of their advanced training. In some states, they have the authority to prescribe medications.

CNSs assume many roles within the health care delivery system. While many are in the clinical setting, others work as educators, administrators, consultants, researchers, change agents, and case managers. CNSs can become specialized in the areas of adult psychiatry, child psychology, community health, home health, gerontology, and medical-surgical, as well as oncology, perinatal critical care, critical care, and rehabilitation. Some nurses in areas of specialty certification classify themselves as CNSs, others use the umbrella term of advanced practice nursing

In March 2000, the number of RNs prepared to practice in at least one advanced practice role was estimated to be about 7.3% of the total RN population. The largest group among the advanced practice nurses was the nurse practitioners, followed by the CNSs. These two groups together made up about 80% of all advanced practice nurses. Although about 36.9% of the CNSs were employed in nursing, only about 24% were practicing under the position title of CNS. Nearly 25% of CNSs reported working in nursing education positions.

Certified registered nurse anesthetist

Nurse anesthesia is the oldest of the advanced nursing specialties. These advanced clinical nurses, called certified registered nurse anesthetists (CRNAs), administer about 65% of the anesthetics given to patients annually in the United States.

Nurse anesthetists make up the third largest group of advanced practice nurses, and were the first professional group in the United States to provide anesthesia services in the 1800s. Their role in surgery is to keep patients as comfortable, pain free, and safe as possible. Nurse anesthetists perform patient physical assessments; take part in preoperative teaching; develop, prepare, and implement the anesthesia plan; select, obtain, and administer anesthesia and other medications and fluids needed to manage the anesthetic; maintain anesthesia throughout the operation and manage the patient's airway and pulmonary status; respond as necessary to emergency situations ensuring airway management , administering emergency fluids or medications, and performing cardiac life support techniques; and follow patients through recovery and into the patient care unit. Essentially, they take care of patients before, during, and after having surgery or giving birth.

CRNAs can sub-specialize in pediatric, obstetric, cardiovascular, plastic, dental, or neurosurgical anesthesia. Some have credentials in critical care nursing and respiratory care.

Nurse practitioner

Nurse practitioners (NPs) are registered nurses who have advanced academic and clinical experience. Because of this additional training, NPs can diagnose and manage common and chronic illnesses, independently or as part of a health care team. Nurse practitioners often can provide primary care previously offered only by doctors and, in many states, they prescribe medications. While in many cases NPs work in collaboration with physicians, NPs have the authority to practice without a physician collaboration or supervision in 18 states.

NPs perform physical exams; diagnose and treat many acute illnesses and injuries; provide immunizations; manage high blood pressure , diabetes, and other chronic conditions; order and interpret x rays and other lab tests; and counsel and educate patients about how they can live healthy lifestyles. NPs focus much of their practice on health maintenance, disease prevention, patient education , and counseling. While they have a strong emphasis on primary care, NPs practice in a wide variety of specialties, including neonatology, obgyn, pediatrics, school health, family and adult health, mental health, home care , geriatrics, and acute care.

Certified nurse-midwife

Certified nurse-midwives (CNMs) focus on the independent management of women's health care, particularly on pregnancy , childbirth , the postpartum period, care of the newborn and the family planning, and gynecological needs of women. They have the authority to write prescriptions. CNMs deliver babies in all types of health care settings, as well as in private homes, and provide primary health care to women, often helping them to realize personal fulfillment through labor and birth. CNMs work independently and in collaboration with other health care providers. They also teach and conduct research.

The trend seems to be that more people are choosing CNMs. As of 1998, there were nearly 278,000 CNM-attended births in the United States. About 400 nurse-midwives pass the national certification exam each year. The practice of nurse-midwifery is legal in all states and the District of Columbia. These advanced practice nurses have prescription-writing ability in 50 states and jurisdictions. Ninety percent of all visits to CNMs are for primary and preventive care. Seventy percent of that was for care during pregnancy and after birth, while 20% was for care outside of the maternity cycle.

Work settings

Clinical nurse specialists

CNSs work in the acute care, long-term care, and intermediate care settings. They work in clinical education within health care facilities, as well as in nursing education programs as faculty teaching nursing. Other settings in which CNSs work include outpatient and ambulatory care, private practice, home health, physician office practice, sub-acute care, government or military service, community health centers, health care administration, private industry (working for drug companies or manufacturers, in managed care and other areas of the private sector), and nurse-managed centers. Within these categories, CNSs work in assisted living facilities; specialized hospital areas, such as cardiac catheterization labs; correctional facilities; dialysis units; parish nursing; and psychiatric hospitals.

Certified registered nurse anesthetist

Nurse anesthetists can work with an physician anesthesiologist, independently or in groups as providers of anesthetics. They work as part of a medical team or independently in any setting in which anesthesia is given, including doctors' and dentists' offices, pain clinics, operating rooms of hospitals, and ambulatory surgery settings. CRNAs who work independently or in groups might have contracts with physicians or hospitals. Some CRNAs work in private practices, while others choose the public sector or the U.S. military. They work in universities as instructors and in research settings as investigators, collaborators, consultants, assistants, interpreters, and researchers. CRNAs also work in surgical and obstetric environments in MRI units, cardiac catheterization labs, and lithotripsy units. In these environments, they provide consultation and implementation of respiratory and ventilatory care, manage emergency situations, and start or participate in airway maintenance, ventilation, and tracheal intubation during CPR .

Nurse practitioner

Nurse practitioners work in metropolitan area clinics and hospitals, as well as in rural areas, inner cities, and medically underserved locations. They work in schools, caring for children, and in nursing homes and assisted living facilities, caring for the elderly and others. NPs work in pediatric, family health, women's health, and other specialty settings. Some work in private practices or in nurse-run group practices.

Certified nurse-midwife

CNMs work in clinical practice in public, university, and military hospitals. They also work in health maintenance organizations, private practices, and birthing centers. Many practice in public heath clinic, and some provide home birth services. More than 50% of CNMs work most often in the office or clinic environment, listing a hospital or physician practice as their employer.

Education and training

Clinical nurse specialists

Nurses must have a baccalaureate degree or its equivalent to enroll in a CNS program. To use the title of CNS, the CNS must have a minimum of a master's degree from an education program that prepares CNSs. The training is graduate-level education. Some universities have a fast track program whereby they will accept individuals who do not have a baccalaureate and move them into a master's program. CNSs also take a certification exam in a specialty, offered by one of the nationally recognized certification entities.

CNS students go through advanced theory and practice training, revolving around the three areas of influence that impact on direct patient care, supervising direct patient care, and patient care systems.

The American Nurses Credentialing Center certifies CNSs as adult psychiatric, child psychology, community health, home health, gerontology, and medical-surgical CNSs. There also are other certifying bodies, including the Rehabilitation Nursing Certification Board, Oncology Nursing Certification Corporation, and American Association of Critical Care Nurses Certification.

The doctoral-level CNS typically focuses on research.

Certified registered nurse anesthetist

Nurse anesthetists are registered nurses who complete two to three years of higher education, beyond the bachelor's of nursing degree or other appropriate baccalaureate degree. They attend accredited nurse anesthesia educations programs, covering all areas of anesthesia. After completing an accredited program, nurse anesthetists must pass a national certification exam to obtain the CRNA designation.

The education for a nurse anesthetist involves about 24 to 36 months of graduate course work. It includes classroom and clinical experience.

In most cases, to be accepted into an accredited school, those who aspire to become nurse anesthetists must have an appropriate four-year degree, an RN license, and at least one year of acute care nursing experience, which varies by program.

Nurse practitioner

NPs receive their advanced educations through programs that award master's degrees. RNs who aspire to become NPs should have extensive clinical experience before applying to an NP program. NP programs include the components of an intensive preceptorship under the direct supervision of a physician or experienced NP and instruction in nursing theory. An increasing number of nurses are becoming prepared as both NPs and CNSs. Those prepared in both roles are more likely to function as nurse practitioners.

Certified nurse-midwife

CNMs are educated in the two disciplines of nursing and midwifery. They must possess evidence of certification according to the requirements of the American College of Nurse-Midwives. Being an RN is a requirement to become a certified nurse-midwife. In some cases, those with baccalaureate degrees in other fields are considered. Upon graduation, CNMs can receive MS (master's of science), MSN (master's of science in nursing), MPH (master's of public health ) degrees or a doctoral degree. About 68% of CNMs have master's degrees, while 4% have doctoral degrees. There are also those who graduate with a certificate or from a nurse-midwifery education program. However, the number of states and employers who require master's-prepared CNMs is increasing. Once in the program, student CNMs receive labor and delivery experience in different types of settings. They must pass a national certification exam to call themselves CNMs.

Advanced education and training

All advanced practice nurses with master's degree can go on to get their doctorate degrees. Often, those with doctorate-level training go into research, administration, or teaching at the university level.

Future outlook

The outlook is good for all types of nurses, especially those at the RN level or higher. It is projected that if current trends continue, demand will exceed supply of RNs by about 2010. It is possible that as many as 114,000 jobs for full-time-equivalent RNs are going to go unfilled nationwide by 2015. This is due to a growing elderly population with mounting health care needs, an aging RN workforce, the expansion of primary care, and technological advances that require more highly trained nurses.

There is a growing demand for RNs with advanced clinical skills. Almost all who graduate have jobs waiting for them.



American Association of Colleges of Nursing. One Dupont Circle, NW, Suite 530, Washington, DC 20036. (202) 463-6930. <>.

American Association of Nurse Anesthetists. 222 South Prospect Avenue, Park Ridge, IL 60068-4001. (847) 692-7050. <>.

American College of Nurse-Midwives. 818 Connecticut Ave. NW, Suite 900, Washington, DC 20006. (202) 738-9860. <>.

American College of Nurse Practitioners. 503 Capitol Ct. NE, #300, Washington, DC 20002. (202) 546-4825. <>.

American Nurses Association. 600 Maryland Avenue, SW, Suite 100 West, Washington, DC 20024. (800) 274-4ANA. <>.

National Association of Clinical Nurse Specialists. 3969 Green Street, Harrisburg, PA 17110-1575. (717) 234-6799. <>.


The Registered Nurse Population National Sample Survey of Registered Nurses—March 2000. U.S. Department of Health and Human Services, Health Resources and Services administration. Bureau of Health Professions. Division of Nursing. <>.

Lisette Hilton

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Advanced Practice Nurses

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Advanced Practice Nurses