Advice to steer you in the right direction
By Janet Selway, DNSc, ANP-BC, CPNP-PC, FAANP
Are you considering becoming an advanced practice registered nurse (APRN)? Healthcare provider shortages, our rapidly aging population, and in- creasing incidence of chronic diseases have put APRNs in the spot- light for their ability to deliver preventive, acute, and chronic disease care. Recent workforce surveys indicate licensed APRNs now account for 7% of the 4 million RNs in the United States.
If you’re thinking of joining their ranks, you’ll need to do thorough research to make an informed decision on which APRN role and education program are right for you. This article describes the four APRN roles, gives current data on each, and offers important points to consider when choosing an APRN education program.
Roles, population foci, and responsibilities
The landmark document Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education delineates APRN roles and gives recommendations about APRN licensure, accreditation, certification, and education. According to the consensus model, to become an APRN, you must complete an accredited master’s or doctorate program that prepares you to function in one of four roles. (See A look at each APRN role.):
- nurse practitioner (NP)
- clinical nurse specialist (CNS)
- certified registered nurse anesthetist (CRNA)
- certified nurse-midwife (CNM).
Once you’ve chosen a role, you must select a population focus applicable to that role. This ensures that you have a foundation of broad-based education before seek- ing additional expertise in a narrow- er specialty. Population foci include:
- family
- women’s health/gender-related
- pediatric
- neonatal
- adult-gerontology
- psychiatric-mental health.
These foci are most relevant to the NP role, which is divided into acute care and primary care.
APRNs need to have sufficient depth and breadth of clinical experience as RNs, and their APRN education must build on their RN competencies. They must be prepared to assume responsibility for health promotion and maintenance as well as assessment, diagnosis, and management of patient problems, including use and prescription of nonpharmacologic and pharmacologic interventions. APRN competencies are defined by patient-care needs, not practice setting.
APRNs must maintain national certification and practice with a significant focus on direct patient care. This focus differentiates APRNs from RNs with other types of graduate education (such as master’s degrees in nursing education or research or clinical doctorates). Many APRNs have clinical doctorates, but at this time a doctor-of-nursing practice (DNP) degree isn’t a requirement for APRN licensure or certification.
A look at each APRN role
Nurse practitioner
Nurse practitioners (NPs) are the largest group of advanced practice nurses (APRNs)—and the group that has experienced the most growth.
Founded 5 decades ago, the NP role grew out of an unmet public health need—primary care for underserved children. The first NP education program was a pediatric one started in 1965 by public health nurse and educator Dr. Loretta Ford and pediatrician Dr. Henry Silver.
NPs provide care across the wellness-illness continuum and are prepared to diagnose and treat patients with undifferentiated symptoms and those with established diagnoses. Most NPs (89%) are prepared in primary-care focused programs. Acute and primary-care NP programs differ in competencies and certification examinations. In 2017, U.S. News & World Report ranked NP second on its “Best 100 Jobs” list.
The most common population foci for NPs are family (62.4%) and adults and geriatrics (23%). National certification for entry-level NPs is based on the six population foci and acute-care or primary-care competencies.
More than 234,000 NPs are licensed in the United States, according to the American Association of Nurse Practitioners. That number has nearly doubled since 2007 when there were an estimated 120,000 NPs. By 2024, the Bureau of Labor Statistics projects that the NP profession will have grown by 35%.
Clinical nurse specialist
Conceived in 1954, the CNS role was first developed in acute-care and mental-health settings. The APRN Consensus Model describes the CNS as a “unique APRN role to integrate care across the continuum and through three spheres of influence: patient, nurse, system.” The National Association of Clinical Nurse Specialists describes the CNS as an expert in a particular specialty, such as a population, type of problem, disease, or setting.
The CNS role encompasses diagnosis and development of plans of care for and management of complex patients. CNSs practice across the lifespan and in all settings, and provide support and expertise to other nurses, physicians, hospital systems, and patients. They serve as patient advocates who provide evidence-based care to improve healthcare delivery and patient outcomes.
The 2016 Clinical Nurse Specialists Census found that 79.8% of CNSs work in an acute-care hospital. Most (74.8%) provide care in adult health/gerontology, and two in three are nationally certified. CNSs are prepared at the masters level, but the survey found that more than 1 in 10 also hold a doctorate.
Nurse anesthetist
Nurses have been administering anesthesia in this country since the Civil War. The certified RN anesthetist (CRNA) credential was established in 1956. CRNAs practice in every state and provide every type of anesthesia in all settings. According to the American Association of Nurse Anesthetists, CRNAs provide anesthesia no differently than physician anesthesiologists. They also provide pain management modalities. CRNAs continue to serve as primary providers of anesthesia for U.S. servicemen and women and are the sole anesthesia providers in two-thirds of rural hospitals.
CRNAs are the third-largest APRN group—and the highest-paid. According to the Bureau of Labor Statistics, in 2015 the annual mean CRNA wage was $164,030. In its 2017 “Best 100 Jobs” lists, U.S. News and World Report ranked nurse anesthetist sixth. CRNA program length ranges from 24 to 42 months. Today, the entry-level requirement for CRNAs is the master’s degree, but by 2025 it will be the DNP. No population focus limitations exist for CRNAs.
Requirements for entry into CRNA practice include successful completion of a nurse anesthesia program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs and passing a certification exam from the National Board of Certification and Recertification for Nurse Anesthetists.
Nurse-midwife
The first nurse-midwifery program was the Frontier Nursing Service in Kentucky, established in 1925. The American College of Nurse-Midwives (ACNM) was established in 1955 and national certification of nurse-midwives began in 1970.
Midwives can be either certified nurse-midwives (CNMs) or certified midwives (CMs). CNMs are educated in both nursing and midwifery. Both CNMs and CMs are licensed independent healthcare providers who provide primary care to women throughout the lifespan. They attend about 8% of all US births.
According to the American Midwifery Certification Board, there were 11,826 CNMs and 101 CMs in the United States as of August 2017. In its 2017 “Best 100 Jobs” lists, U.S. News and World Report ranked nurse midwife as 15.
Services provided by midwives include contraception, preconception care, pregnancy care (including childbirth and postpartum), and newborn care during the first 28 days. Midwives also may treat male partners for sexually transmitted infections and reproductive health.
Midwives work in various settings, such as birth centers, private offices, clinics, and the home. They are prepared to perform comprehensive health assessment, health promotion, wellness education, and disease prevention.
Since 2010, a master’s degree has been the entry-level requirement for both CNMs and CMs. A list of accredited CNM programs is available on the ACNM website. About one-third offer the option of a DNP CNM program. Most offer the master’s in nursing and a post-graduate certificate option. Several provide the option of completing requirements for dual roles—CNM and women’s health NP.
How to choose an APRN education program
Completing an APRN program takes a great deal of time and resources, so be sure about your decision before enrolling in a program. Even if you’re certain about which APRN role and population focus you want, you may find greater clarity if you spend some time shadowing an APRN who practices in your preferred role and population. (See Online information sources.)
Academic ability is crucial. APRN programs seek students who stand a good chance of handling the rigor of a tough graduate program. Program directors look at under-graduate nursing course grades, particularly in the sciences, such as anatomy, physiology, and pharmacology. Many won’t consider applicants with grade point averages (GPA) below 3.0. But GPA isn’t the whole story. If you had a less-than-stellar GPA in your BSN program, be prepared to explain why in your admission essay.
All APRN programs require students to complete the “3 P’s”: advanced pharmacology, advanced pathophysiology, and advanced physical/health assessment. These foundational courses for advanced clinical courses require new critical-thinking skills. If you didn’t do well in the undergraduate versions of these courses, think about why you didn’t and what you could do differently to succeed in the advanced versions. (Keep in mind that many programs have a pro-visional admission option.)
Online Information sources
Visit the links below for more information on advanced practice registered nurse (APRN) education programs and the four APRN roles.
- American Association of Colleges of Nursing: Your Guide to Graduate Nursing Programs
aacn.nche.edu/publications/brochures/GradStudentsBrochure.pdf - American Association of Nurse Anesthetists: Become a CRNA
aana.com/ceandeducation/becomeacrna/Pages/default.aspx - American College of Nurse Midwives: Become a Midwife
midwife.org/Become-a-Midwife - American Association of Nurse Practitioners: Planning Your NP Education
aanp.org/education/student-resource-center/planning-your-np-education - National Association of Clinical Nurse Specialists: Key Findings from the 2014 Clinical Nurse Specialists Census
nacns.org/wp-content/uploads/2016/11/CensusInfographic.pdf
Find out about prerequisites for the program you wish to apply to. For example, CRNA programs re- quire 1 year of acute-care nursing experience and a BSN or other appropriate bachelor’s degree. What’s considered an appropriate acute-care setting or an alternate bachelor’s degree may vary across CRNA programs. Be aware that some APRN programs may be open to direct-entry BSN-to-MSN degrees or some variation, whereas others require at least 1 or 2 years of RN experience.
Whichever program you choose, know that good computer skills are a must. You’ll be expected to navi- gate course web software, search library databases, watch online lectures, and use word processing, PowerPoint®, email, and statistical software. If your computer skills are marginal, consider taking a course to improve them.
Clinical preceptors
Find out if the APRN program you’re interested in can help you find a clinical preceptor. Some programs may expect you to find one on your own. Good clinical preceptors are in short supply and great demand; getting a commitment from a preceptor can take months.
Can you afford the program?
Does the program you’re interested in offer scholarships or other financial assistance options? Could you work full time while going to school? In many cases, managing a full-time job while attending school full time isn’t realistic and could be self-defeating. Many APRN students work part time and do well, but some programs discourage students from working while enrolled.
If you’d have to work a grueling schedule to pay the tuition at an expensive school, consider whether going to that school is worth it. Be realistic; sleep deprivation from a heavy work schedule can make the critical thinking required in APRN courses difficult. A less expensive school may be a better fit for you.
Interviews and admission forms
Many APRN programs require a written admission essay. To gauge your writing skills, some may require you to write an essay on the spot. Your admission essay should demonstrate excellent writing skills and convey not just your best qualities but also your passion for nursing and your desired APRN role. So be sure to convey your passion. If you seem lukewarm about your decision, it’s probably not the right decision for you.
Expect to interview in person or through electronic communication. For an in-person interview, be punctual, dress appropriately, and articulate exactly why you want to become an APRN. Explain why you think you’re capable of doing this and describe your goals. Program directors are looking for leadership qualities, excellent interpersonal skills, the ability to speak well, and an appropriate level of self-assurance.
A challenging and gratifying choice
APRNs are passionate about their roles and enjoy the added knowledge and responsibility that comes with the territory. They enjoy using new skills to help people while still maintaining a core nursing per- spective. Generally, their job satisfaction is high and compensation is good. Administering anesthesia, managing a patient’s diabetes, making a tough medical diagnosis, or delivering a healthy baby can be terrifying at times—yet profoundly gratifying.
Janet Selway is an assistant professor in the School of Nursing at The Catholic University of America in Washington, DC.
