Issues up close

Advanced practice registered nurses (APRNs) are increasing in number and in value to the healthcare delivery system. As more people have access to health care, expanded opportunities for APRNs bring up questions about scope of practice. “Should I do this?” is the question we hear most often from APRNs.

For two categories of APRNs—certified registered nurse anesthetists (CRNAs) and certified nurse midwives (CNMs)—there is little confusion about scope of practice regarding care settings and patient age limits. CRNAs administer anesthesia and provide pain-care management to patients of all ages in hospitals, surgical centers, and outpatient settings. CNMs provide health care services to women from adolescence to beyond menopause. CNMs also care for normal newborns during the first 28 days of life and treat male partners for sexually transmitted infections.

But for certified nurse practitioners (CNPs) and clinical nurse specialists (CNSs), questions arise. The recommended approach is to think through scope-of-practice questions to make informed decisions, using the models for decision making and professional nursing practice regulation as guides. (See Scope-of-practice decision-making model for CNPs and CNSs.)

Questions about patient ages

Your first resource for APRN practice questions is your state nurse practice act. Some nurse practice acts or regulations specify age ranges for NP or CNS practice, but many states do not.

The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (2008) (APRN Consensus Model) does not rigidly define age limits, but advocates for APRN services to be defined by patient needs. For example, a patient with cystic fibrosis may be best served by the pediatric NP who has been his or her primary care provider since childhood.

NPs and CNSs certified by the American Nurses Credentialing Center (ANCC) may recall that earlier versions of test content outlines included age ranges. ANCC removed age ranges to be consistent with the APRN Consensus Model.

Settings of care

The APRN Consensus Model states that scope of practice is not setting specific but based on patient care needs. Recall that CNS education typically includes the full spectrum of wellness and illness; there are no primary or acute care CNS categories. However, healthcare employers who credential APRNs often have questions about settings of care for acute and primary care NPs.

Primary care and acute care NPs

There is considerable overlap along the primary care-acute care continuum. Specialty clinics and long-term care settings may predominantly serve acutely ill patients, or their patients may be chronically ill but clinically stable. Patient acuity can vary greatly within settings. Acute care and primary care CNPs should question prospective employers about the typical acuity of the population they will serve.

Questions about scope of practice

You need to be able to articulate your role and function. Ask yourself, “If something went wrong, could I convince a jury that I was competent to care for that patient?”

Does experience count?

Prospective APRN students need to think through their future career goals when considering types of programs. For instance, an experienced intensive care unit nurse who enrolls in a family NP program would not be equipped after graduation to work as a hospitalist. Prior RN experience in an acute care setting does not enable a primary care NP to practice as an acute care CNP.

On-the-job experience as a CNS or CNP does not prepare an APRN to change specialties. For example, a family NP who is currently practicing in acute care does not qualify to take the acute care NP certification exam. On-the-job training coupled with continuing education or APRN fellowship can prepare a CNS or CNP to practice in a subspecialty.

Experience with technical skills is important for safe practice, credentialing, and privileging. CNSs and CNPs should keep track of the special procedures they practiced in their APRN program and perform in their work experience.

Selected references

Buppert C. Can a Family Nurse Practitioner Work in the ED or ICU? Medscape Nurses. October 2, 2014. www.medscape.com/viewarticle/832164. Accessed October 14, 2014.

Buppert C. Is an NP obligated to treat a patient outside of the NP’s certification, if an employer tells the NP to do it? August 3, 2014. Nurse Practitioners of New York.
https://npny.enpnetwork.com/nurse-practitionernews/56131-is-an-np-oblig-ated-to-treat-a-patient-outsideof-the-np-s-certification-if-an-employer-tells-the-n. Accessed October 9, 2014.

Hudspeth R. Smart Practice: Finding Answers. Advance Healthcare Network for NPs and PAs. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/Finding-Answers-2.aspx. Accessed September 30, 2014.

Tumolo J. Making a switch: Tips for transitioning to a new specialty or subspecialty. Advance Healthcare Network for NPs and PAs. July/August, 2014;1(3):39. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Making-a-Switch.aspx. Accessed September 30, 2014.

Andrea Brassard is director of Health Policy at ANA. Diane Thompkins is a senior certification program analyst with the American Nurses Credentialing Center.