The Choice is Yours
APNs step out of the physician's shadow and into increasingly responsible roles as health care providers

By Alicia Hugg, RN
May 6, 2002

Picture yourself on a sled being pulled along a snowy countryside by a team of Alaskan huskies rushing toward an igloo, where a seriously ill child awaits the care that only you can provide. Sound unrealistic? This scenario may be a bit dated, because both housing and transportation in Alaska now are similar to that found in the lower 48, and propeller airplanes are the preferred mode of transport these days. But if you're considering a career as an advanced practice nurse, chances are that a similar vision may have influenced your thinking about a move into this evolving field.

Whether you become a nurse practitioner or an advanced clinician in one of several specialties, you will find your role as an advanced practice nurse different from that of the traditional registered nurse.

The advanced practice nurse belongs to a growing segment of registered nurses who have satisfied clinical and educational requirements beyond the two to four years of basic nursing education required of all RNs. They fall into four major categories: nurse practitioner, certified nurse-midwife, clinical nurse specialist and certified registered nurse anesthetist.

Nearly 140,000 nurses are in advanced practice positions in the United States, according to the American Nurses Association, many filling a need created by "chronically underserved populations"-the elderly, poor and those living in isolated areas, where access to adequate health care services is difficult or nonexistent.

As APNs step out of the physicians' shadow and into increasingly responsible roles as health care providers, there is a heightened awareness of their value and skills, with some patients beginning to prefer their hands-on, unhurried care to that of their primary care physicians. Moreover, a great percentage of primary and preventive care can be done by a nurse at a lower cost.

Educational qualifications for an APN vary from state to state, but national accreditation is possible in some areas of practice through professional associations. Increasingly, legislation favoring the expansion of practice is being proposed and passed, moving the profession toward a national standard.

The nurse practitioner

Nurse practitioners are registered nurses with advanced practice preparation and specialized training licensed to provide health care services either independently or in collaboration with physicians and other health care professionals. Working in clinics, nursing homes, hospitals or their own offices, they perform physical exams, diagnose and treat common illnesses or injuries, and order and interpret diagnostic, laboratory and radiology studies.

Even though NPs, who number more than 71,000 in the United States, have been around for more than 30 years, most people are only vaguely aware of their roles as health care providers. Additionally, health plans largely have overlooked the potential of NPs and other advanced care practice nurses as primary care providers. But this is changing, as a broad-based coalition of NPs push for visibility through national and regional associations, as well as in legislative halls.

"Nurse practitioners can practice more independently than most areas of advanced practice," said Melanie Goodman, JD, MN, CPNP, president of the California Coalition of Nurse Practitioners, an organization that keeps its members abreast of legislative and health insurance issues affecting them. "They follow their patients' problems and decide where treatment should occur-the physician or specialist's office or the hospital."

Goodman observes that many nurses choose independent practice because it gives them a sense of ownership and investment return. She is quick to stress that the return is usually more in self-accomplishment than in money.
Julie Worley, MS, FNP, RN, agrees. After exploring many possibilities in nursing, the Chicago native, who now lives in rural Tennessee, settled on advanced practice.

Worley is moderator of the nurse practitioner reference section and forum for nursingnet.org, a Web site dedicated to nursing practice of all disciplines. She also is president of her local APN and physician assistant association, as well as a contributing editor to the Internet magazine The Practicing Nurse. She works part time with a family practice physician.

"I do think many nurses go into advanced practice nursing so that they can be more independent and make more medical and treatment-related decisions for patients," she said. "I am so glad I became an NP. I love my job."

Worley tells aspiring nurses that they must have a strong desire to care for people. "To me, nursing needs to be almost like a calling," she said.

Veronica Thrasher, Ph.D., M.Ed., PNP, became an NP because she saw a need for more minority nurse practitioners. As a school nurse in Massillon, Ohio, Thrasher approaches nursing from a holistic viewpoint and advocates for care that focuses on the whole being, not just the illness.

"I think nurses should be sensitive to what their patients are not saying, their environment and diet. Being a nurse practitioner also allows me a better vantage point from which to advocate for improved health care for minorities," she said.

Marilyn Hockenberry, Ph.D., RN, PNP, FAAN, combines her interest in research to improve patient outcomes with her profession as a clinician and educator. As director of the pediatric nurse practitioner program at Texas Children's Hospital in Houston, the largest children's hospital in the world, Hockenberry oversees 90 pediatric and clinical NPs in all areas of specialties.

Hockenberry trained at the University of Texas M.D. Anderson Cancer Center, specializing in pediatric oncology because of the "deficiency of physicians" practicing oncology. Physicians who chose oncology, she observed, had greater time constraints and could not spend adequate time with their young patients.

"I discovered that NPs were able to spend more time with patients and provide continuity of care and nursing from a holistic approach," she said. "We were able to look at growth and development of the sick child and to work with the family. There are research areas for us as nurses to improve patient outcomes. Our philosophy is to improve both the continuity and quality of patient care from a nursing role, while working with staff and fulfilling responsibilities to academics and research."

A researcher with five funded grants, Hockenberry is looking for ways to improve the care of children with cancer through research. The hospital supports a nursing scholarship program through which 18 nurses are given one day a week for a year to develop research projects that directly affect patient care.

For example, one nurse is monitoring vital signs during sedation for echocardiograms to assess safe limits, while another is developing a support group for parents of children with liver disease. Hockenberry sees much potential for growth in the research scholarship area and envisions "centers of excellence" throughout the hospital as a result.

Hockenberry is recognized as a full professor by the hospital medical staff, many of whom are faculty at the Baylor College of Medicine, a rare honor for someone who is not a physician.

"I chose pediatric oncology because of the children," she said. "All children are special, but children with chronic illnesses are extra special. They give back so much. They teach us so much about respecting and cherishing life. The future is endless as far as opportunities for advanced practice."

The certified nurse-midwife

About 7,400 certified nurse-midwife professionals work in the United States. Most have a year and a half of specialized education beyond nursing school, either in accredited certificate programs or increasingly at the master's level.

CNMs provide care not only at delivery, but also give well-woman gynecological and low-risk obstetrical care, including prenatal, labor and delivery and postpartum. Their services have proved invaluable, both economically and from a quality, utilization and risk-management perspective.

A 1993 ANA meta-analysis of CNM care disclosed that nurse-midwives performed fewer fetal monitors, episiotomies and forceps deliveries, gave fewer IVs, delivered fewer low-birthweight and premature babies, and had shorter patient hospital stays.

Seattle-based Wendy Wheeler, MSN, RN, was drawn to midwifery because it presented an opportunity to take care of women. Wheeler, who is board certified by the American College of Nurse-Midwives, is a full-time NP for King County Women's Health, providing care and education on family planning.

"One of the advantages of being a CNM is caring for healthy people." She views childbirth as a life event and one that she does not have to "fix." Wheeler's advice to nurses considering advanced practice careers:

"Go for it. You have choices not available to you as a staff nurse. In Washington state, NPs can be completely independent of doctors. More patients are requesting NPs because we take the time to listen to patients and provide a lot more education."

A strong indication that NPs are being taken seriously in Washington state is the recently passed legislation permitting them to dispense narcotics. "Prescriptive authority of narcotics will save a lot of time and bolster our credibility as health care providers," Wheeler said.

The clinical nurse specialist

A CNS is a registered nurse with an advanced nursing degree, master's or doctoral who is an expert in a specialized area of clinical practice such as mental health, gerontology, cardiac or cancer care and community or neonatal health.

The ANA reports that more than 58,000 clinical nurse specialists work in a variety of settings, including hospitals, clinics, nursing homes, their own offices and other community-based settings such as industry home care and HMOs. CNSs provide primary care and psychotherapy in a wide range of disciplines. They conduct health assessments, diagnose, treat, consult, conduct research, are educators and hold administrative positions in a variety of health care settings. Services provided by CNSs are reimbursable by Medicare, Medicaid, CHAMPUS and private insurers.

Gennifer Newton, MSN, RN, uses her clinical practice skills to help students at Seattle's Shoreline Community College through their maternal child nursing rotation. Newton's present occupation is a natural offshoot of her early days as a staff nurse in a labor and delivery unit. She continues to work part time as a labor and delivery nurse to maintain her clinical skills.

"I love teaching and interacting with students," she said.

The CRNA

The ANA reports that 25,238 registered nurses are CRNAs. These nurses complete two to three years of education beyond the four-year bachelor's degree and must meet national certification standards. The oldest of the advanced practice specialities, CRNAs administer more than 65 percent of all anesthetics given to patients annually and provide all of the anesthetics given in 85 percent of rural hospitals. While CRNAs sometimes work under the supervision of anesthesiologists, the majority of their services are performed independently in the operating room, dentist offices and ambulatory surgical centers.

"There are many attractions to the specialty of anesthesia. I believe there are two main motivators. The first is the overall challenge-we are held to the same standards and practice as physician anesthesiologists," said Air Force Maj. Thomas Evans, MS, CRNA, of Elmendorf Air Force Base in Alaska.

While the training is "long and difficult," Evans said it's worth it in the end. "You stand out among your peers as a highly trained nurse specialist. You gain respect from nurses, surgeons and friends," he said.

"The second motivator is that financial rewards are great."

Contact Alicia Hugg at rosewind09@earthlink.net.