The Advanced Practice Nursing role began in the US in the 1960s to address healthcare needs, especially in rural/underserved areas. There are now over 350,000 NPs who provide primary care. Initial challenges included lack of understanding of the role and funding educational programs. Over time, regulatory mechanisms recognized APN authority and titles. APN education requires a master's degree in a nurse practitioner (NP), clinical nurse specialist (CNS), nurse midwife (CNM), or nurse anesthetist program. While autonomy varies by state, APNs are projected to continue expanding access to care and playing a key role in the future of healthcare in the US.

1. The experience of
implementing Advanced
Practice Nursing in the USA
PAHO/WHO Collaborating Center for Nursing Research
Development of the University of São Paulo at Ribeirão Preto
College of Nursing
October 22, 2021
Joyce Pulcini, PhD, PNP-BC, FAANP, FAAN

2. The author declares no conflicts of interest.

3. International Council of Nursing. (2020) Guidelines for Advanced Practice Nursing - 2020 – ICN Guidelines. A Guidance Paper.
Available at: https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf

4. Advanced Practice Nurse (ICN, 2020)
An Advanced Practice Nurse (APN) is a generalist or
specialised nurse who has acquired, through additional
graduate education (minimum of a master’s degree), the expert
knowledge base, complex decision-making skills and clinical
competencies for Advanced Nursing Practice, the
characteristics of which are shaped by the context in which they
are credentialed to practice (adapted from ICN, 2008). The two
most commonly identified APN roles are CNS and NP.

5. Clinical Nurse Specialist (CNS)
A Clinical Nurse Specialist is an Advanced Practice
Nurse who provides expert clinical advice and care
based on established diagnoses in specialised clinical
fields of practice along with a systems approach in
practicing as a member of the healthcare team (ICN,
2020)

6. Nurse Practitioner (NP)
A Nurse Practitioner is an Advanced Practice Nurse
who integrates clinical skills associated with nursing
and medicine in order to assess, diagnose and
manage patients in primary healthcare (PHC) settings
and acute care populations as well as ongoing care for
populations with chronic illness (ICN, 2020)

7. Educational Preparation for APNs
Educational Preparation beyond that of a generalist or
specialized nurse education at a minimum requirement of a
full master’s degree programme
Formal recognition of educational programmes for APN (CNS
or NP)
A formal system of credentialing linked to
defined educational qualifications
Adapted from ICN 2020.

8. Regulatory Mechanisms for APN Practice
Authority to diagnose
Authority to prescribe medications
Authority to order diagnostic testing and therapeutic
treatments
Authority to refer clients/patients to other services and/or
professionals (ICN, 2020)

9. Authority to admit and discharge clients/patients to hospital
and other services
Officially recognized title(s) for nurses working as APNs
Legislation to confer and protect the title(s) (e.g. Clinical
Nurse Specialist, Nurse Practitioner)
Legislation and policies from an authoritative entity or some
form of regulatory mechanism explicit to APNs (e.g.
certification, credentialing or authorization specific to country
context) (ICN, 2020)

10. How did the APN implementation
process take place in the U.S.A.?
• The APN started in the U.S. by forward thinking nurses who saw an opportunity
for public health nurses to meet the needs of underserved populations in the U.S.
especially those in rural and underserved areas.
• Four types of APNs:
• Nurse Practitioners (NPs)
• Clinical Nurse Specialists (CNSs)
• Certified Registered Nurse Midwives (CRNMs)
• Certified Registered Nurse Anesthetists. (CRNAs)
• The First NP program was a pediatric NP program in Colorado in 1965, which
focused on primary care of children in the community. This program, headed by
an RN, Loretta Ford and Henry Silver, an MD, was first a certificate program
and later was part of a university program.
• Later programs evolved into other types of NP programs.

11. What are the APN specialty areas in your
country?
• NPs- > 350,000 NPs (2021)
• Family NPs (69.7%),
• Adult-Geriatric NPs (10.8%),
• Pediatric Nurse Practitioners,
• Psychiatric-MH Nurse Practitioners across the lifespan,
• Women’s Health NPs
• Neonatal NPs
• Acute Care NPs (Adult or Pedi);
• CNMs- >12,805 (2021)
• CNSs- >72,000 (2021)
• CRNAs- >65,000 (2021)

12. Credentialing of Nurses in the U.S.
Specialty Organization Year of First
Certification
Nurse Anesthetists AANA (1931) 1941
Nurse Midwives ACNM (1929) 1971
Nurse Practitioners ANA (ANCC)
Later AANP,
NCC, PNCB
1976
Psychiatric Cl.
Nurse Specialists
ANA (ANCC) 1976

13. NP Facts (AANP, 2021)
More than 36,000 new NPs completed their academic programs in 2019–2020.2
88.9% of NPs are certified in an area of primary care, and 70.2% of all NPs deliver primary
care.3
81.0% of full-time NPs are seeing Medicare patients and 78.7% are seeing Medicaid
patients.3
42.5% of full-time NPs hold hospital privileges; 12.8% have long-term care privileges.3
96.2% of NPs prescribe medications, and those in full-time practice write an average of 21
prescriptions per day.3
NPs hold prescriptive privileges, including controlled substances, in all 50 states and D.C.
In 2020, the median base salary for full-time NPs was $110,000.3
The majority of full-time NPs (59.4%) see three or more patients per hour.3
NPs have been in practice an average of 11 years.3
The average age of NPs is 49 years.3
Source: https://www.aanp.org/about/all-about-nps/np-fact-sheet

14. What were the main challenges faced
during the implementation of APN role?
Getting Started:
• Lack of understanding of the role by consumers, policymakers, and others
especially as the role was initiated
• Funding of programs was necessary: early funding by U.S. Dept. of Health and
Human Services was key
• Certificate vs. University Programs
Opposition/Barriers:
• The opposition of key groups like physicians, but also other nurses
• Lack of understanding or the role by nursing and medical organizations

15. What is the difference between Advanced
Practice Nursing and MD or RN practice?
• APNs take on roles that were once in the realm of medical practice and incorporates them
into nursing practice such as assessment, diagnosis, and treatment of illness.
• APN practice gives patients access to nursing care.
• In the case of CRNAs part of the difference is in giving anesthesia.
• Location of practice may also differ ie NPs are more likely to be in primary care in the U.S.
• But NPs can function as acute care NPs in an advanced role in managing critical care
patients similar to medical residents but always in collaboration with an interdisciplinary
team.
• If the location of practice is a hospital or acute care facility care is more likely to be
interdisciplinary with less independence as makes sense.
• Midwifery is not part of RN practice in the U.S. so delivering babies is an advanced practice
role.
• Nurses and APNs are different in these additional skills that overlap with physicians

16. What competencies and skills should
the Advanced Practice Nurse learn in the
training process?
American Association of Colleges of Nursing (www.aacnnursing.org)
• The Essentials: Professional Competencies for Nursing Education
National Organization of Nurse Practitioner Faculties (www.nonpf.org)
• The National Task Force on Quality Nurse Practitioner Education
Criteria for Evaluation of Nurse Practitioner Programs, 5th Edition (2016)
• Common Advanced Practice Registered Nurse Doctoral-Level Competencies (2017)
• Nurse Practitioner Core Competencies with Curriculum Content (2017)
• Adult-Gerontology Acute Care and Primary Care NP Competencies (2016)
• Population-Focused Nurse Practitioner Competencies (2013)

17. What is the curricular structure of a
master's degree for the training of
Advanced Practice Nurses?
• 3 Ps: Across the Lifespan
• Advanced Pathophysiology
• Advanced Health Assessment
• Advanced Pharmacology
• Graduate Core Courses based on MS or DNP Essentials
• Policy
• Leadership
• Quality
• Research
• Role Courses
• Specialty Clinical Courses- Population Focused

18. Building a Curricula: LACE Model (AACN, 2011)
APRN
Role
Population
foci
Specialty
Regulation
Competencies
3 Ps (Advanced Pathophys,
Pharmacology,
Health Assessment)
NP, CRNA, CNM CNS
Core competencies in
Population context
Professional Organizations
(e.g. oncology, palliative
care, nephrology)
Professional Certification
Graduate Core Master’s or
DNP Essentials

19. APRN REGULATORY MODEL
APRN SPECIALTIES
Focus of practice beyond role and population focus
linked to health care needs
Examples include but are not limited to: Oncology, Older Adults, Orthopedics,
Nephrology, Palliative Care

Licensure
occurs
at
Levels
of
Role
&
Population
Foci
Family/Individual
Across Lifespan
Adult-
Gerontology*
Neonatal Pediatrics

 
   
POPULATION FOCI
APRN ROLES
Nurse
Anesthetist
Nurse-
Midwife
Clinical Nurse
Specialist
Nurse
Practitioner *
Women’s
Health/Gender
- Related
Psychiatric-
Mental Health**
AACN, 2011

20. What are the strengths and
weaknesses for implementing APN?
Strengths:
• The NP role extends the workforce so as to allow patients to receive more and better
care.
• Studies have shown that the NP in primary care is equally effective as MD care and that
NPs can provide up to 90% of the same services as MDs in these settings.
• In our country MDs are choosing medical specialties since they are paid considerably
more in these roles.
• For MDs the lowest paying specialties are in pediatrics and internal medicine.
Weakness:
• Lack of full practice authority in half the states – Full practice in 24 states and DC.

21. Regulation and Legislation for APNs
• Regulation:
• Regulations are different in each state which is a weakness since no
consistence exists across states
• Each state creates a legal definition of the roles and
• Rules and regulations governing those roles
• Most stay in the U.S. due to regulatory restrictions
• Certification:
• National certification is highly developed in the U.S.
• Required in most states for entry into practice.
• Recertification is every 5 years
• U.S. has a very sophisticated and regulated mechanisms for development of
the national entry examinations for APNs

22. How autonomous is the Advanced
Practice Nurse?
• Autonomous in 24 states plus DC.
• Other states have various mechanisms which limit their full practice authority
including limited prescriptive authority or some type of physician supervision.
• National commissions recommend full practice authority such as Nursing 2030.
• It is important to note that it took us 50 years to get to this point of autonomy
and this is a process not something that happens overnight.
• We try to use the term collaboration vs supervision

23. Is there a career path for Advanced
Practice Nurses?
• APNs tend to like to stay in practice since it is highly satisfying to have a long
term relationship with patients and their families.
• In other countries the term career path suggests movement into administrative
or management roles.
• So, yes some NPs do move into these roles but most like to stay in clinical
practice.
• I have several NP colleagues who have been in primary care for more than 30
years with a panel of their own patient and who are very satisfied with this.
Some have tried administration and moved back into clinical practice
• In 2020, the median base salary for full-time NPs was $110,000.

24. How do you project the role of nursing
for the future in your country?
• In the U.S. nurses have been the most trusted profession for more than 16 years.
• I believe that the APN role is very much a part of the reason or this.
• I think this for many reasons including the fact that since the beginning of the
APN roles, nursing has attracted the best and the brightest nurses to enter the
field.
• The NP role is very attractive to young nurses who understand the need for
nursing to be its own profession and to function more independently from other
professions.
• For this reason these roles have attracted many males breaking the stereotype
that this is a female dominated profession.

25. Projected Role (cont’d)
• I have observed that the status of nursing has risen continually because the
profession has much higher status now than it did many years ago.
• This is also reflected in the fact that the pay for nurses is high and it is now one
of the highest paying jobs for new graduates in the U.S.
• Obviously the pay level does not accelerate once someone is in the field in the
same way as other fields such as law or medicine.
• We have many people entering nursing from other fields getting a second BS
degree who would choose nursing over medicine or who want to serve other
people. For many nursing is a second career.
• Covid has had a big effect in nursing in the U.S. though due to burnout and high
stress and many have retired or left the field with this second wave

26. References and Websites
AANP (2021) NP Facts. Available at: https://www.aanp.org/about/all-about-nps/np-
fact-sheet
American Association of Colleges of Nursing (AACN) www.aacnnursing.org
International Council of Nursing. (2020) Guidelines for Advanced Practice Nursing -
2020 – ICN Guidelines. A Guidance Paper. Available at:
https://www.icn.ch/system/files/documents/2020-
04/ICN_APN%20Report_EN_WEB.pdf
National Academy of Medicine (2020). The Future of Nursing 2020-2030.
https://nam.edu/publications/the-future-of-nursing-2020-2030/
National Organization of Nurse Practitioner Faculties (NONPF) www.nonpf.org

27. The Future is Yours to Create!!
Questions ??
My Email: pulcinjo@gwu.edu