Advanced Practice Nursing : AJN The American Journal of Nursing

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Advanced Practice Nursing

Clark, Angela P. PhD, RN, CNS, FAAN, FAHA

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AJN, American Journal of Nursing 109():p 17-18, January 2009. | DOI: 10.1097/01.NAJ.0000343101.62178.5b
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A master's degree lets you choose among four career paths.

Whether they are drawn to caring for children or older adults, working in a primary care practice, or providing emergency or critical care, nurses have many career options. No matter what path is chosen, having clinical experience and additional education are musts for all nurses. Some opt to expand their professional capabilities by becoming an advanced practice nurse (APN).

In the United States, there are four roles for an APN: clinical nurse specialist, NP, certified nurse midwife, and certified registered nurse anesthetist. A master's degree is required for each role, and further education may be necessary. The American Association of Colleges of Nursing recommends that by 2015 all APNs be required to have a doctorate in nursing practice (see, although the nursing profession as a whole hasn't yet embraced this concept; vigorous debate continues.

If you're considering an APN role, it's important that you understand what each position entails. Also see “Your Guide to Certification” on page 32 and online at


The clinical nurse specialist (CNS) provides advanced nursing care to specialty or subspecialty populations with complex health problems. Employment settings vary. A CNS focuses on improving the quality of care across the organization, as well as strengthening a culture of patient safety.

For example, a CNS may work in a hospital or acute care facility to improve patient outcomes for a particular population, such as critical care or pediatric patients. Another popular setting is a specialty clinic—such as for diabetes, heart failure, or wound care—in which the CNS performs focused patient assessment, patient and family education, and care management. Providing mental health care is another option that combines counseling, medication oversight, and other care that improves patients' lives.

In many states, a CNS is authorized to prescribe medications and other supplies as part of a collaborative practice with physicians.


In the United States most NPs are educated to provide primary care, and they can specialize with populations such as adults, children, or families. They may be employed by hospitals or physician groups. NPs can also work in acute care, sometimes filling a role similar to that of a hospital resident by providing care for a select group of patients during hospitalization. NPs can perform procedures such as lumbar puncture or central line insertion, and they may go on rounds for particular types of acutely ill patients.


Providing holistic maternal health care, the scope of practice of the certified nurse midwife (CNM) varies by state, but she or he typically works independently to provide care to low-risk patients. In cases of high-risk pregnancy, such as patients with certain chronic diseases or pregnancy-related complications, the CNM may work collaboratively with physicians. CNMs offer prenatal care, delivery in the home or hospital, and postpartum care, all while focusing on family-centered care. They also often provide maternal health care for expectant mothers in underserved populations, which makes their service even more valuable. CNMs' outcomes, which are well documented, demonstrate lower rates of cesarean sections and patient complications, and shorter hospital stays.


Often working collaboratively with physician anesthesiologists to improve the care of patients undergoing surgery, certified registered nurse anesthetists (CRNAs) provide care to thousands of patients who receive anesthesia every year. This role has existed for more than 125 years. In rural settings, CRNAs may be the only providers who administer anesthesia, and numerous studies have demonstrated their safe patient outcomes.1,2 CRNAs today have a strong educational background in both science and practice. Their care has been shown to result in outcomes similar to those of anesthesiologists in decreasing postoperative complications and patient mortality.2


If you think you want to expand your career and become an APN, consider the following suggestions as you research the role you are interested in:

  • talk with APNs about what they like and don't like about their jobs
  • check out a variety of master's degree programs to see if the curricula interests you
  • meet with students in the master's degree programs to see what it's like from their perspective
  • remain informed about the potential requirement change to a clinical doctorate degree. Obviously, the program of study for a clinical doctorate would be longer and more expensive; however, distance learning programs for completing at least part of the course work are becoming more common.

Most importantly, think about what you want to be doing in, for example, 10 years. Explore the options and follow your dreams. Advanced practice nursing could change your life in unexpected and exciting ways.


1. Pine M, et al. Surgical mortality and type of anesthesia provider. AANA J 2003;71(2):109–16.
2. Simonson DC, et al. Anesthesia staffing and anesthetic complications during cesarean delivery: a retrospective analysis. Nurs Res 2007;56(1):9–17.

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