APRN Scope of Practice and Responsibilities

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Introduction   

When hearing the phrase advanced practice nursing, what comes to mind? Whether you’re new to nursing or have been a nurse for many years, you have definitely worked with advanced practice registered nurses (APRNs). You might also be aware that advanced practice nursing is one of the fastest growing health care careers with lots of potential for registered nurses (RNs) from all specialties and educational backgrounds. People will always need someone to provide direct patient care, and APRNs work in all 50 states providing essential care to millions of people nationwide. The information in this course will serve as a valuable resource for nurses interested in learning more about the scope of practice and responsibilities for APRNs nationwide. 

Defining Advanced Practice Nursing 

What Is Advanced Practice Nursing? 

Advanced practice nursing is nursing care performed at the graduate level, also known as mid-level practicing health care. An APRN is when an RN has the certification, training, and licensure of being a APRN in their state of work. APRNs are also known as certified nurse practitioners (CNPs). APRNs work in all 50 states, have prescriptive authority in all 50 states, provide direct patient care, and also, depending on their specialization, provide specialized patient care. For instance, a pediatric nurse practitioner (PNP) is a type of APRN who has completed a graduate level nursing program to provide direct patient care to pediatric patients. Another example of advanced practice nursing is a women’s health nurse practitioner (WHNP), a type of APRN who completed a graduate level nursing program to provide direct patient care to patients regarding their sexual and reproductive health (1,2,3,4).   

Advanced practice nursing work can vary state by state, as many states have their own regulations and policies regarding the scope of work for APRNs. In addition, several workplaces have their own policies for advanced practice nursing work, especially as APRNs have grown in popularity as a health care career. Given the wide variety of scope of practice, types of nurse practitioners, and options to be certified as various types of nurse practitioners, the American Association of Nurse Practitioners (AANP) and the American Nursing Association (ANA) provides a good overview on the various types of APRN specialties and licensing options.  

It is important to check with your specific workplace and state(s) of licensure to determine the full extent of scope of practice for APRNs in your area. Because advanced practice nursing is such a wide nursing career path, there are many advanced practice nursing career options, such as nursing research, consultant opportunities, direct patient care, legislative advocacy, and more (4,5,6,7). Various types of APRNs include NPs, certified registered nurse anesthetists (CNRAs), and certified nurse midwives (CNMs). 

At its core, advanced practice nursing involves critical thinking skills, patience, and communication when working with patients, insurance companies, and health care professionals. Nursing remains the most trusted profession for a reason, and several studies show that patients report higher levels of patient satisfaction with APRN care. While advanced practice nursing can be a challenging career, many APRNs report high levels of satisfaction in their career path (6,7). 

How and Where Are Advanced Practice Registered Nurses Working? 

Almost every health care organization and system in America hires APRNs. While mainstream depictions of APRNs vary significantly in pop culture, APRNs work in all 50 states, especially in rural and underserved parts of America. In fact, several private practices, public health departments, correctional facilities, community health centers, birth centers, schools, universities, and more routinely hire APRNs. Some APRNs also establish their own business and work autonomously (if that is an option in their state, as some states allow for APRNs to practice autonomously, whereas others do not).  

It is estimated that there are over 300,000 licensed APRNs in America with an increase of APRNs predicted in the next decade as health care continues to evolve. Depending on state and local regulations and scope of work requirements, APRNs often work with a collaborating physician regarding patient care. The extent of the work of a APRN can depend on their training, scope of work at their work place, and local and state regulations, as every state has their own regulations for the scope of work for APRNs (1,2,3). 

What Educational Requirements Are Needed to Work in an Advanced Practice Registered Nurse?  

APRNs can be any RN of any working background who has completed at least a Bachelor of Science in Nursing (BSN). Most advanced practice nursing degrees are at the Master’s or doctoral level, such as a Master of Science in Nursing – Women’s Health Nursing or Neonatal Nursing. Typically, a RN will earn a BSN then progress to obtain a graduate level degree in nursing with a focus on their specialty.  

RNs who do not have a BSN (such as nurses who have an Associate of Science in Nursing) can complete additional coursework through several nurse-bridge programs to complete a BSN to then progress onto graduate level nursing studies. Some RNs also transition directly from a Bachelor’s to graduate level degree in nursing in what is known as direct-entry or direct access programs. However, some graduate level nursing programs often require at least a few years of experience in nursing or health care prior to applying for a graduate level nursing programs (1,2,3,4,5).  

If you are interested in learning more about the educational path to become an APRN, it is recommended to look into specific school’s requirements, as requirements for admission to various graduate level nursing programs can vary significantly. After someone has completed their graduate level studies in their specific nursing path, they can then apply to take their certifying nurse practitioner exam through their respective nursing accreditation organization. The most common type of APRN is family nurse practitioner (FNP), compromising an estimated 70% of APRNs in America. That said, there are several specialties, and many APRNs hold education and certifications for multiple scopes of advanced practice nursing. Like education and career paths, consider doing your research into various NP careers near you if this is a path you are interested in (1,2,4,5,7).  

Furthermore, every workplace and state have different requirements for nurses interested in APRN careers. For instance, some workplaces prefer on the job training instead of additional formalized education. Some workplaces will not consider applications without nursing experience, even if you have a graduate level degree in advanced nursing. Some states also have various practice requirements and hours needed to maintain your APRN licensure. Consider doing your research advanced practice nursing before deciding to go back to school if this is a career path you are interested in (1,2,7). 

Advanced Practice Nursing Landscape 

The Advanced Practice Nursing Job Market 

Like nursing careers in general, salary varies by state, such as Texas or Alaska, and place of employment, such as a large health care organizations or private practices. Like other nursing career paths, APRNs with more experience tend to have a higher salary than APRNs without experience. In fact, some RNs will note that their salary might even decrease from transitioning from the role of an RN to APRN depending on the job market and job location. It is important to understand that average salaries can vary depending on prior nursing experience, work location, qualifications, and place of employment (1,2,3,6,7).  

In addition to salary, with the rise of telemedicine, remote patient monitoring, and other aspects of virtual nursing care, advanced practice nursing is expected to increase in demand in more remote parts of America and in health care deserts. As mentioned above, possible places of employment for APRNs include universities, hospitals, private practices, clinical research facilities, community health centers, telehealth companies, pharmaceutical companies, correctional facilities, the military, health care organizations, nonprofit organizations, and more. This is not an exhaustive list by any means, as new companies and places are hiring for APRNs, such as larger technology companies and schools as well (1,2,3,6,7).  

The Advanced Practice Nursing Scope of Work 

People often think that APRNs only write prescriptions every day or only work under the direction of a physician. The truth is, while APRNs can write prescriptions and can work under the direction of a physician, expected workloads and job duties can vary depending on the full job description. In fact, APRNs also provide extensive patient education, can assist in surgeries, and can perform outpatient procedures depending on their education and scope of work laws and regulations in the state.  

Some common tasks associated with APRNs include: (1,2,3,6,7). 

• Providing annual exams throughout the lifespan or within their specific patient populations 

• Managing acute and chronic health conditions in outpatient and inpatient settings 

• Managing surgical complications, such as hemorrhage or infection 

• Administering immunizations and interpreting labs 

• Monitoring health parameters 

• Collaborating with various health care professionals for health outcomes, such as working with doctors, other APRNs, physician assistants (PAs), and more 

• Providing evidence-based information to patients regarding their health concerns 

That was quite the list, but that is not 100% of tasks for APRNs. In fact, that’s just the tip of the iceberg, especially as more APRNs enter the workforce. In addition, the role of autonomous advanced practice nursing care can vary state by state depending on state legislation and practice, as each state has their own regulations. Because advanced practice nursing is such an expansive and growing career, clarifying your scope of work and duties and also being aware of your scope of work depending on your state and workplace are essential. It is also important to remember that the scope of work for a APRN mostly depends on that nurse’s education, training, qualifications, nursing regulations, and workplace practices (1,2,3,4).  

Advanced Practice Nursing Responsibilities 

Depending on the state in which an APRN practices, some nurses can practice patient care autonomously, meaning that they are responsible for direct patient care and outcomes. While advanced practice nursing scope can be similar across states, because of various state laws regarding autonomous advanced nursing care, it is important to check your laws in your state(s) of practice. Advanced practice nursing responsibilities can include similar tasks to those mentioned above, in addition to supervising fluoroscopy procedures, performing minor outpatient surgeries, serving as pillars of health care in their communities, and more. Because of the wide scope of nursing care and patient care, APRNs must be realistic with themselves about their comfort levels providing care autonomously and be aware of their limits and responsibilities (1,2,3,6,7). 

Advanced Practice Nursing by State 

Every state has their own board of nursing (BON) that dictates the scope of work for APRNs. For instance, the requirements for an autonomous APRN license in Florida is not the same as autonomous APRN practice license in Nebraska. In addition, states with full practice authority (FPA) have adjusted their legislation and requirements since the COVID-19 pandemic began, causing confusion and complications for APRNs, their workplaces, and patient care flow. For the most up-to-date regulations regarding APRNs scope of work, it is recommended to contact and view the BON protocols per each state directly (7,8).  

Advanced Practice Nursing and Healthcare 

APRNs are not going anywhere. In fact, there is a significant demand for APRNs, especially in rural and underserved areas in the United States and globally. Health outcomes in America are among some of the worst in the developed world, and APRNs have consistently been shown to provide quality care and have excellent patient care outcomes. Healthcare in general is expecting for a higher demand for APRNs as older physicians and health care providers in general retire and as America has a larger aging population (1,2,7,8). 

In terms of workplace dynamics, unfortunately, burnout is a common concern for many APRNs and can contribute to the large fluctuations in the APRN workforce. The leading cause for burnout among APRNs is the practice environment. Many APRNs often report not being able to practice to the full extent of their scope of work and having to deal with administrative concerns on the job.  

If you are considering being an APRN, it is recommended to take your time to assess a workplace environment and administration prior to working there. Many people choose to become a APRN for the love of nursing care and quality of life of an APRN’s career. However, many things can affect overall quality of life as an APRN, such as the types of schedules you would work, the income and benefits, and the number of patients you are expected to care for. Negotiating and discussing your needs prior to accepting a position is essential to prevent burnout and to ensure a long career as an APRN (1,2,7,8).  

Advanced Practice Nursing Alternative Career Paths 

While there is a growing demand for APRNs and the need for providers to provide direct patient care, there are also several career paths for APRNs. If you are interested in advanced practice nursing, but not sure if you want to provide direct patient care long-term, here are some alternative career paths for APRNs: (1) nurse educator, (2) legal nurse consultant, (3) professor, (4) nurse researcher, (5) nurse writer, or (6) consultant. Many APRNs also complement their nursing skills with additional training as a sexual assault nurse examiner (SANE), preceptor, or board member (1,2).  

Nursing Considerations 

The Nurse’s Role in Advanced Practice Nursing 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While the scope of work of APRNs can vary state by state and by various workplaces, here are some general insights into the role of APRNs in patient care. 

1. Take a detailed health history. Often times, the transition from RN to APRN can be overwhelming for nurses. As an APRN, while you may have staff that takes a detailed history for you, it is important to confirm the patient history to provide the most accurate, comprehensive care possible. If a patient is complaining of symptoms, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities. Take the time to establish care with that patient. 
2. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. While millions of people take medications, there are many people who take medications and are no longer benefiting from the medication. Ask patients how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history. Make sure to specify if the patient is taking any over-the-counter supplements or herbs as well. 
3. Ask about family history, especially in outpatient care settings. Family history can be essential in providing patient education and screening for health conditions, such as hyperlipidemia.  
4. Be willing to be honest with yourself about your comfort level discussing topics and providing education on medication and health conditions. If you are not comfortable discussing something, please refer to another staff member or consult with your collaborating physician.
5. Communicate the care plan to other staff involved for continuity of care. For several patients, health care often involves a team of mental health professionals, nurses, primary care specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care.
6. Stay up to date on continuing education and legislation related to advanced practice nursing, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information. 
7. Many people in the general public are not aware of the scope of work for APRNs or even know APRNs exist as a profession. Be sure to take your time and explain to your patients your work, your capabilities, and your collaborating team members roles as well. There are also many stigmas and stereotypes of APRNs, such as that they are not as competent as physicians or cannot perform quality patient care, so be sure to take your time in answering questions about your scope of work and ability to provide quality care.  

Interest in Advanced Practice Nursing 

Truly, a career in advanced practice nursing is rewarding personally, professionally, financially, and emotionally. APRNs are among one of the fastest growing careers in health care, and many APRNs report high levels of satisfaction with their work. That said, APRNs can vary significantly in their work. The scope of work for a CRNA is not the same as a CNM. A PNP is not going to work with the same patient population as an adult-geriatric nurse practitioner (AGNP) will. APRNs working in Tennessee do not have the same scope of work as APRNs in New York. If a nurse is interested in advanced practice nursing, they should consider why they want to be an APRN and what they love about nursing. A nurse should also consider how comfortable they are with the unpredictable nature of health care, the responsibility associated with direct patient care, and the experience of being a direct care provider.  

If you think you are interested in a career in advanced practice nursing, doing your own research and assessing the job market are great starting points to see if this is a career path for you. If you are considering being an APRN, I would recommend that you ask yourself if you truly are passionate about nursing and patient care. 

What Patients Should Know About Advanced Practice Registered Nurses  

Patients should know that APRNs are licensed health care providers in all 50 states who can provide direct patient care, write prescriptions, and perform certain procedures. Patients should know that APRNs are nurses by training and are eager and willing to provide patient care.  

Upcoming Research 

There is extensive publicly available literature on advanced practice nursing via evidence-based journals and in nursing research. 

Case Study 

Tracy, a 33-year-old working as a nurse in the operating room, has worked in nursing for six years and enjoys working in this setting. Lately, Tracy has been thinking about looking into advancing her nursing career as she would like more experience with pain medication and more autonomy at work. Tracy is working in the operating room and she sees one of the more experienced CRNAs prepare a patient for a knee surgery. After the surgery, Tracy asks the CRNA to talk about their work. The CRNA speaks to Tracy for a bit and tells Tracy about a local nursing school hosting a graduate program seminar with programs to become a FNP, CRNA, and CNM. Tracy considers attending this seminar.  

• What are some ways various health care professionals work together to provide quality care to patients?  

• What are some barriers with cross-collaboration you have encountered in the workplace? 

• How can a nurse learn more about the CRNA profession if they have not worked in an operating room before?  

Later in the week, Tracy is finishing up a shift and monitoring her last patient. The surgeon is performing a routine knee replacement, and the patient’s vital signs are stable. As the surgeon is finishing up the procedure, the patient’s vitals suddenly shift, and the patient starts to move their fingers. The patient is supposed to be unconscious, so the CRNA and surgeon immediately assess the patient’s vitals. The CRNA also adjusts the pain medication. This is the first time Tracy has seen a patient move during a procedure in which they are supposed to be sedated, and Tracy is wondering how they would have managed an emergency like this if they were in the CRNA’s shoes.  

• What sort of notions do you have about RN and APRN work? Have you ever seen complications in patient care? 

• How do you feel about independently managing complications in patient care?  

A few weeks later, Tracy attends the graduate program event on graduate nursing programs. Tracy wants to still look into being a CRNA, but is still wondering how they will manage complex situations in anesthesiology care. Tracy also asks the supervisor if the employer is willing to reimburse for tuition or if working part-time while in the program is an option. Tracy really enjoys working at the hospital but is also curious about CRNA work outside of a hospital as well. Tracy also has never worked at an outpatient clinic and would like to explore APRN options.  

• What questions should Tracy ask before taking on a CRNA role? 

• What are some perspectives a nurse can bring to the team compared to other members in clinical care and technology services? 

Conclusion

Nursing is here to stay, and APRNs are going to be a major player in the ways health care is delivered in the U.S. and globally. While many people may be unaware of the role of APRNs and their prevalence in many health care settings, APRNs provide essential health care to millions of people every day in the U.S.  

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