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Melissa A. Saftner and Maria N. Ruud
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OVERVIEW OF ADVANCED
PRACTICE REGISTERED
NURSING
Advanced practice registered nurses (APRNs) are at the forefront of the
rapidly changing healthcare system, filling myriad roles in organizations
where they provide cost-effective, high-quality care. APRNs are found in
virtually every area of the American healthcare system: clinics, hospitals,
community health, government, administration, policy-making boards,
and private practice. In addition, APRNs have expanded practice into in-
ternational and transglobal arenas. They serve the most economically dis-
advantaged as well as the elite. APRNs are deans, educators, consultants,
researchers, policy experts, and, of course, outstanding clinicians.
Advanced practice registered nursing is an exciting career choice with
many opportunities and challenges. The challenges are often related
to the rapidly changing healthcare environment that is contingent on
funding decisions made at the state and federal levels of governmental
funding. Prospective payment systems, health inequities, required out-
come measures, and spiraling costs are daily APRN practice realities.
Technology improves diagnostic and treatment results; genetic research
is unraveling complex pathophysiology and immunotherapy; and so-
phisticated “big data” electronic infrastructures change the way infor-
mation is gathered, stored, analyzed, and shared. Innovative care models
are common and include telehealth programs, integrated or complemen-
tary modalities, and retail clinics. These and other trends result in a
rapidly changing healthcare system, ready for the influence and influx
of APRNs.
Graduate education prepares APRNs to be key players in these complex
systems. Midrange nursing theories provide strong conceptual foundations
for APRN practice and nurse scholars. Nursing research uncovers scientific
evidence for best practice, and research utilization skills enable APRNs to
bring fresh ideas and proven interventions to healthcare consumers.
Copyright Springer Publishing Company. All Rights Reserved. 3
From: Advanced Practice Nursing Roles, Sixth Edition
DOI: 10.1891/9780826161536.0001
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4 I Foundations of Advanced Nursing Practice
Complex policies and laws require that APRNs routinely navigate in-
surance reimbursement, management, and health policy regulations.
Although APRNs were traditionally educated to provide advanced nursing
care in specific clinics or hospital units, they now often work across system
boundaries as they follow their patients through transitions of care. For
example, APRNs care for patients in outpatient clinics, admit them to the
hospital, assist in coordinating discharge plans, and collaborate with long-
term care organizations, perhaps working with public health agencies to
return their patients to their home communities. These new cross-system
care models result in regulatory complexity for APRNs. They must be able
to legally provide care across systems. Working across state lines results
in even more complexity due to each state’s laws and regulations. In ad-
dition, each healthcare organization can interpret state and federal laws
and regulations in its own professional staff policies. Organizations can be
more restrictive than laws, but they cannot be less restrictive. For example,
state law may not require a signed collaboration agreement between a phy-
sician and APRN, but the healthcare system may mandate such an agree-
ment. Given considerable variations among practice environments, APRNs
must be experts and proactive in the business and regulatory policies and
processes. Staying current is best accomplished by participation in role-
specific APRN professional organizations.
ADVANCED PRACTICE REGISTERED NURSING:
THEN AND NOW
Advanced specialization of nurses beyond their formal entry-level educa-
tion has a long and proud history of innovative risk-takers and key events.
To capture that history and unify the advanced nursing specialists, the
term "advanced practice registered nurse” (APRN) became the common
umbrella term used to designate four specialty roles of nurses with formal
postbaccalaureate preparation: certified nurse-midwives (CNMs), certified
registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and clin-
ical nurse specialists (CNSs).
Nurse anesthetists and nurse-midwives organized nearly a century ago
and were the first APRNs to develop national standards for educational
programs, professional organizations, and certification. NPs and CNSs
standardized their preparation, certification, and licensing incrementally
in recent decades. Various scholars and professional organizations have
documented the unique history of each APRN role.
A number of factors led nursing leaders to delineate these four APRN
roles. A critical factor was obtaining legal status to be directly reimbursed
for their nursing services, a gradual process first achieved by nurse-
midwives more than 35 years ago and subsequently expanded through
federal and state legislation for the other three roles. Reimbursement laws
and regulations require that nursing be able to specify the qualifications of
these reimbursable APRNs, which contributed to increased standardiza-
tion of titling, education, and national certification.
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1 Overview of Advanced Practice Registered Nursing 5
Public protection was another factor that led to the delineation of the
APRN roles. State boards of nursing are mandated by state legislatures to
safeguard the public from unsafe practice, and over time, all states have
implemented laws and regulations to ensure that nurses in the four roles
have specific expertise and skills. Some states have accomplished this
through a second-level licensure process. In other states, APRNs are reg-
ulated through title protection and scope of practice laws. In 2008, APRNs
reached an agreement defining a desired national model of regulation
for the United States. This agreement, the Consensus Model for APRN
Regulation: Licensure, Accreditation, Certification, and Education, is known
as the LACE model (APRN Consensus Workgroup & APRN Joint Dialogue
Group, 2008). The National Council of State Boards of Nursing (NCSBN)
created a map in 2011 to track the implementation of the consensus model
by the United States. A numerical point system to rate implementation of
the LACE model was created by NCSBN with 28 points indicating full con-
sensus adaptation by a state and 0 points indicating no adaptation (NCSBN,
2017b). By 2017, 15 states had fully implemented the LACE model and re-
ceived a score of 28, 10 states and the District of Columbia enacted 75% to
96% (21–27 points) of the LACE model, 17 states scored 14–20 points, and 8
states received fewer than 14 points (NCSBN, 2017b). The changes in state
laws required complex legislative initiatives led by APRNs (Kopanos, 2014).
Most other states’ APRN groups are working toward amending state nurse
practice laws by adopting the LACE model of regulation.
A final factor influencing APRN standardization has been the adoption
of national APRN curricular guidelines and program standards. These
standards were developed by many specialty organizations and brought
through negotiations to consensus by nursing organizations such as the
American Association of Colleges of Nursing (AACN), the American Nurses
Association (ANA), and the National Organization of Nurse Practitioner
Faculties (NONPF). APRN educational standards have been endorsed by
numerous nursing specialty organizations in the past decade and are used
for national program accreditation.
Nursing’s Scope and Standards of Practice (ANA, 2015b) defines APRNs
as having advanced specialized clinical knowledge and skills through
master’s or doctoral education that prepares them for specialization, ex-
pansion, and advancement of practice. "Specialization" is concentrating or
limiting one’s focus to part of the whole field of nursing. "Expansion" refers
to the acquisition of new practice knowledge and skills, including know-
ledge and skills legitimizing role autonomy within areas of practice that
overlap traditional boundaries of medical practice. "Advancement" involves
both specialization and expansion and is characterized by the integration
of theoretical, research-based, and practical knowledge that occurs as part
of graduate education in nursing. This APRN definition, which is regulated
by state and federal laws, does not include nurses with advanced prepara-
tion for administration, informatics, education, public health, or research;
those roles are considered “advanced nursing practice” and are not regu-
lated, a fine but important legal distinction.
