This week we kick of a series of articles that give a better understanding of APRNs, what role they play in medicine, the level of education involved, and the legal struggles they’ve faced. Our first article is by guest writer Michelle Knowles, FNP, APRN, explaining the history that lead to the roles that APRNs currently fill.
The History of APRNs
An Advanced Practice Registered Nurse (APRN) is a baccalaureate prepared registered nurse (RN), who has also accomplished a graduate degree in nursing in one of the following four roles of APRN:
- The Certified Registered Nurse Anesthetist (CRNA)
- The Clinical Nurse Specialist (CNS)
- The Certified Nurse Midwife (CNM)
- The Nurse Practitioner (NP)
In the late 1800’s and early 1900’s, registered nurses in the poor areas of New York City, the Indian reservations and the remote areas of the Appalachian Mountains of Kentucky were making home visits to patients. These public health RNs laid the foundation for APRNs.
These nurses were not able to communicate easily with a physician due to lack of phones. They had to make assessments and develop diagnoses for their patients. The nurses provided physical and psychological care as well as dispensing physician-prescribed medications and home remedies, which they carried in their bags. The concept of visiting nurses treating underserved patients spread to other areas and became common practice. Most visiting nurse groups formed medical oversight groups and standing orders, so they could continue their valuable work without risking their nursing license. Visiting nurses were working autonomously and to the full extent of their nursing training to provide care to thousands of citizens across the country.
In the 1950’s the American Nurses Association developed a definition of nursing, which limited the ability of nurses working outside the hospital to work to the full extent of their education. The definition did not allow nurses to prescribe or diagnose, which severely limited the functions of the public health nurse. After a few decades of frustration over restrictions and lack of nursing autonomy, the APRN roles were developed.
Certified Registered Nurse Anesthetist (CRNA) Historical Timeline
- During the mid 1850s, the rate of injury or death from anesthetics was very high, so nurses were taught to give anesthetics to patients undergoing surgery. Nurses were chosen over other medical professionals because of their professional demeanor and their attention to the patient. Nurses trained to give anesthetics were crucial during the Civil War. As they perfected their technique the nurse anesthetist profession was born. Nurse anesthetists are considered the first clinical nursing specialty. Death and injury rates dropped dramatically with nurse anesthetists providing anesthesia.
- The first formal program for nurse anesthetists was at St. Vincent’s Hospital in Portland, Oregon in 1909. The Lakeside Hospital School of Anesthesia was the first school of anesthesia and was established by a nurse anesthetist around 1920.
- The first certification exam was given in 1945 and educational programs were standardized in the 1950s.
- By 1998 all nurse anesthesia programs were required to be at the graduate level. The military has relied heavily on nurse anesthetists as the primary anesthesia providers starting during WWI and continuing to combat zones around the world today.
Clinical Nurse Specialist (CNS) Historical Timeline
- The idea of the CNS started in the1930s with nurses learning extra skills to care for patients in the hospital setting. This role was closely tied to the traditional functions of the RN and evolved out of a need for more advanced nursing care of the hospitalized patient. The CNS expanded the plan of care of the hospitalized patient, but didn’t cross over into diagnosing and prescribing.
- By 1960, the CNS was established as an APRN role with formal graduate education, which focused primarily on hospital and psychiatric patients.
Certified Nurse Midwife (CNM) Historical Timeline
- Nurse midwifery began in the 1920s with public health nurses trying to meet the needs of childbearing women in underserved areas. In Leslie County, Kentucky, which was one of the poorest and most inaccessible counties in the country, access to health care was nearly impossible. A CNM, named Mary Breckenridge, founded the Frontier Nursing Service. She set up clinics in three remote counties. Since there were few roads, the nurses mainly traveled by horseback to provide care to families. The nurses diagnosed and treated patients, delivered babies and provided emergency care. They had standing orders to cover medications they dispensed. Over nine years they delivered more than 250 babies and provided care for thousands of children.
- By the 1970s, the number of nurse midwives grew to about one thousand. National education standards in graduate programs across the country and national certification were implemented, which further highlighted the quality of CNMs. Women were rediscovering normal birth and choosing to have their babies at home instead of in the hospital. The number of CNMs continues to grow each year.
Nurse Practitioner (NP) Historical Timeline
- In response to a nationwide physician shortage in 1965, the concept of a NP was rooted in the roles of the early public health visiting nurses. Loretta Ford, assistant professor of nursing at the University of Colorado, along with pediatrician, Dr. Silverman, developed the role of the NP. Together, they developed the first training program for public health nurses to receive expanded formal training, and the first class had less than 10 students. The first NP program educated pediatric nurses to go into the rural areas of Colorado to provide comprehensive well-child care and to manage common childhood health problems. The concept took off and expanded into other universities.
- The first formal NP graduate program was established in 1967 in Boston, MA.
- In the 1970s NP programs moved from a certificate program to bachelors degree programs along with some masters degree programs as well. During this time the role expanded from the pediatric population into family practice and many other specialties.
- In the 1990s NP programs moved away from bachelors degree and became masters degree programs.
- Over the past five years NP programs have evolved into clinical doctorate degree programs and will soon be the only option to becoming a NP.
- Today, there are over 222, 000 licensed NPs in over 10 different clinical areas in the United States.
APRNs are fulfilling the legacy of the early visiting nurses, who provided so much care to so many underserved citizens in this country. Access to healthcare remains a major problem for many Americans. APRNs are capable of alleviating this problem, yet many states limit APRNs ability to practice to the full extent of their education and training. Currently, only one-third of the states have adopted full practice authority licensure and practice laws, which refers to the ability for the APRN to practice autonomously without any physician oversight.
Be sure to read our next articles in this series to learn more about the education and training requirements for APRNs as well as the ongoing legislative battles for full practice authority.