The Pulse | Thursday, September 24, 2020
The Evolution of Advanced Practice Nursing
By Rhoda Redulla, DNP RN-BC
The World Health Organization (WHO) declared 2020 as the Year of the Nurse and Midwife. As we honor and celebrate nurses and midwives around the globe, we pause and reflect on the contributions of various nursing roles, including our advanced practice nurses (APNs). APNs are skilled in providing a variety of services, including expert clinical practice, preventive care, health promotion and maintenance.
In the United States, APNs have four distinct categories: Nurse Practitioner (NP), Certified Nurse Anesthetist (CRNA), Certified Nurse-Midwife (CNM) and Clinical Nurse Specialist (CNS). NPs or CNSs are more frequently found in the gastroenterology unit, whereas CRNAs are more common in the procedural area, such as the endoscopy unit.
Nurse Practitioners (NP)
Evolution of Training and Preparation
Currently, all NPs are required to complete a master’s or doctoral degree program and have advanced clinical training beyond their initial professional registered nurse (RN) preparation. They undergo national certification, periodic peer review, clinical outcome evaluations and adhere to a code for ethical practices.
Evolution in Practice
The role of the NP evolved from the need for quality, affordable healthcare, particularly in underserved populations (Martin, 1999). In 1996, the Institute of Medicine (IOM) recognized the demographic projections for the aging population in the U.S., creating a population with more complex needs. Hospitals were urged to expand the use of APNs to diverse settings.
NPs assess patients, order and interpret diagnostic tests, make diagnoses and initiate and manage treatment plans — including prescribing medications. In a systematic review that examined the impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction and cost, results showed improvement in these outcomes (Woo, Lee, & Tam, 2017). For example, patients who receive care from NPs often have fewer emergency room visits, shorter hospital stays and lower medication costs (AANP, 2020).
Clinical Nurse Specialists (CNS)
Evolution of Training and Preparation
The CNS role evolved from the need for expert nurses in highly complex patient care environments, particularly in critical care. (Jacobs, 1997 as cited in Martin, 1999). Practice specialty for the CNS may be defined based on population (e.g., pediatrics, geriatrics or women’s health); setting (e.g., emergency or critical care); disease or medical subspecialty (e.g., diabetes or oncology); type of care (e.g., psychiatric or rehabilitation); or type of problem (e.g., pain, wounds, stress) [NACNS, 2020].
Evolution in Practice
Clinical nurse specialists provide expertise and support to nurses caring for patients at the bedside, help drive practice changes throughout the organization and ensure the use of best practices and evidence-based care to achieve the best possible patient outcomes (NACNS, 2020). CNSs lead the creation of nurse-driven pathways, review procedures and policies, and influence many aspects of patient care.
Today, it is hard to imagine healthcare without APNs. They deliver cost-effective care, comparable to physicians. Newhouse et al. (2011) conducted a systematic review of 37 studies and found consistent evidence that cost-related outcomes such as length of stay, emergency visits and hospitalizations for care delivered by NPs are equivalent to those of physicians. In addition, the level of APN autonomy will continue to grow with — hopefully — more unified and clear standards to guide their practice and development.
Certified Nurse Anesthetist (CRNA)
Evolution of Training & Preparation
Nurse anesthetists have been providing anesthesia care to patients in the United States for more than 150 years. The CRNA credential was initiated in 1956. The title "nurse anesthesiologist," which is synonymous with the title "nurse anesthetist," is used by some CRNAs (AANA, 2019).
Until the late 19th century, anesthesia training programs did not exist. The job of delivering anesthetics was often assigned to medical students, house officers, nurses or orderlies, none of whom received formal instruction in anesthetic procedures. As science expanded the role of the physician by improving our understanding of disease and how to surgically treat illnesses, the nurse’s role also broadened. Nurses took on duties once limited to physicians; in the operating room, this included administering anesthesia. (Ray & Desai, 2016)
Evolution in Practice
Today, CRNAs are anesthesia professionals who safely administer more than 49 million anesthetics to patients each year in the United States, according to the American Association of Nurse Anesthetists (AANA) 2019 Member Profile Survey (AANA, 2019). The scope of practice of CRNAs spans the preoperative/preprocedure, intraoperative/intraprocedure, postoperative/postprocedure, pain management and other services such as providing emergency critical care and resuscitation services.
CRNAs also evolved to be the primary providers of anesthesia care in rural America, enabling healthcare facilities in these medically underserved areas to offer a wide range of services including obstetrical, surgical, pain management, and trauma stabilization (AANA, 2019).
As we honor all nurses during the 2020 Year of the Nurse, it is important to remember just how far nursing has come. While the APN role can take on many forms within gastroenterology, APNs are vital to the unit and the patients they serve.
References:
American Association of Nurse Anesthetists [AANA] (2019). Retrieved from https://www.aana.com/membership/become-a-crna/crna-fact-sheethttps://www.aana.com/
American Association of Nurse Practitioners. All About NPs. Retrieved from https://www.aanp.org/about/all-about-nps April 1, 2020.
Fong Yeong Woo, B., Xin Yu Lee, J., Wai San Tam, W. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review. Human Resources for Health, 15(1):63.
Martin, R. (1999). The Role of the Transplant Advanced Practice Nurse: A Professional and Personal Evolution. Critical Care Nursing Quarterly, 21(4):69-76.
National Association of Clinical Nurse Specialists (NACNS). (2020). Retrieved from https://nacns.org/about-us/what-is-a-cns/
Newhouse R, Stanik-Hutt J, White K, et al. (2011). Advanced practice registered nurse outcomes 1990-2008: A Systematic Review. Nursing Economics; 29(5):230-50.
Ray, W.T., Desai, S.P. (2016). The history of the nurse anesthesia profession. Journal of Clinical Anesthesia, 2016-05-01, Volume 30, Pages 51-58