Advanced practice nursing in the United States, before and during the Covid-19 era
As a public health nurse in France, I am often asked to explain my work as an American advanced practice nurse (APN) (table I), a profession which has progressively become international. This article briefly describes the APN role in the US, from its history to current demographics and educational requirements. Also, the response to the Covid-19 pandemic is addressed, with an example of the author's work which supports the idea that this public health challenge affects all of us, even if our practices diverge.
Advanced practice in the United States
To envision the future, we need first to look at the past
The United States (US) encounters the need for major health care reforms under the Joe Biden presidency as of January 2021, partly due to the public health crisis from the Covid-19 pandemic as well as a shortage of health care professionals. The negative impact of the pandemic in the US would have been worse if the APN role had not been created. To understand the full context of current advanced practice nursing, it is important to consider the history of APNs which began in the US at a time when a shortage of physicians, unequal access to health care services, rising health care costs, and an interest by nurses to advance their profession converged to create a need for radical changes in the health care system.
The first APNs in the US started in the 1950s with the Clinical Nurse Specialist (CNS) role (table I), involving specialty clinical practice and expertise which combines direct clinical care and indirect care (leadership, etc.) . In 1965, Dr Loretta Ford, a community health nurse (figure 1) and Dr Henry Silver (a pediatrician) launched the first nurse practitioner (NP) program at the University of Colorado to provide community-based care for children . This was encouraged by both the women's and civil rights movements, as well as by physicians who collaborated to form new models of care. Still, at times, some opposition came from both medical and nursing organizations, though the movement continued and federal funding began to support nursing education. In a variety of medical disciplines, NPs began to practice either with other physicians, or in independent practice with remote physician supervision.
The 4 types of US APNs
There are over 4 million registered nurses in the US (the majority with a bachelor's level education), and, as of 2018, approximately 12% of them were educated for advanced practice (up from 8% in 2008) . Four types of APNs exist (master's level education requiring national testing for certification): NP (over 290,000 individuals representing 69% of APNs, with 90% certified in primary care and other domains including emergency care (table II) , CNS (20% of APNs, certified to care for adult, pediatric, or neonatal populations), Certified Registered Nurse Anesthetist (CRNA, 9% of APNs), and Certified Nurse Midwife (CNM, 2% of APN). Now, the goal for APNs is to obtain a Doctorate of Nursing Practice (DNP).
Other non-physician professionals also exist and may work as a team with an APN, but they are not considered to be APNs. A physician's assistant (PA) differs in that they are not required to have a nursing education and, as their name states, are legally more focused on assisting the physician. A medical assistant, on the other hand, usually completes only a few months of education, and can assist nurses, APNs, PAs, and/or doctors of medicine (MDs) with more secretarial type of work and some technical tasks (e.g. taking vital signs, performing ECGs, etc.).
What are the specific competencies of APNs?
APNs, particularly NPs and CNSs, have integrated aspects of the medical model such as diagnosis and treatment along with the nursing model of health prevention, promotion and education. Since their inception, APNs have provided high quality of care as shown by several studies (not possible to cover in detail here) [5-7]. Figure 2 summarizes NP competencies for entry into practice decided on by the National Organization of Nurse Practitioner Faculties (NONPF) . These core competencies highlight the global approach of NPs to patient care, balancing scientific-based, quality clinical care with involvement in policy and health care systems change.
However, it took over 50 years for APNs in the US to reach a consensus on titles and core competencies across the numerous states. In 2008, the Advanced Practice Registered Nurse (APRN) consensus model was endorsed, serving both to improve patients' access to care, and ensure standardized quality of care (including evidence-based education relying on physical exam, pathophysiology, and pharmacology) . APNs are required to complete lifelong continuing medical education.
Reaching beyond American borders
The American Association of Nurse Practitioners (AANP) was an active part of forming the International Council of Nurses Nurse Practitioner/Advanced Practice Nurse Network (ICN NP/APNN), which was formally launched in 2000 to promote international collaboration supportive of the APN role . Furthermore, the AANP is comprised of an international committee (of which the author is a former member) which advocates for the advancement of the APN role internationally, and recently leads an International Advanced Practice Nurse Ambassador Program in the interest of mentoring NPs (or nurses in an advanced role) by providing a scholarship to attend the national conference as well as other benefits . It has been inspiring to see the NPs and advanced practice nurses AANP has chosen from other countries who have truly been activists for both the APN role and patients in their home countries.
High mortality affects both the United States and France
The Covid-19 pandemic that started in Wuhan, China, in December 2019, is now unfortunately affecting the entire world. This includes the US and France, which are among the top 10 countries to be affected in terms of the country's general population: as of mid-January 2021 (figure 3), the US is 4th and France is 7th in terms of mortality (deaths per 100,000 population) . In terms of case-fatality ratios (the number of deaths divided by the number of confirmed cases), the France ranks as 10th (2.4%) and US follows as 16th (1.7%) .
As far as we know, patients with chronic illnesses such as diabetes and hypertension are at higher risk of worse outcomes from Covid-19  therefore the APN (particularly working in the primary care, chronic-illness setting) is ideally positioned to evaluate these vulnerable patients.
Improving patients' access to care with APNs
The political work of moving states towards a more autonomous practice for APNs (full practice authority) began far before Covid-19 hit, and will continue even more strongly after the pandemic subsides. In response to the Covid-19 pandemic, the majority of states across the US temporarily suspended some or all existing collaboration, supervision and protocol requirements for NPs as shown in figure 4 . Only a minority of states remain unchanged.
I have learned that in practice when performing consultations, the primary care NP performs many of the same clinical actions as a MD, yet with a holistic nursing approach, from diagnosis to treatment and follow-up. I have worked as a NP since 2003, and my first job was split as a NP in direct patient care and as clinic supervisor, serving as the link between management and other NPs and MDs. Therefore, I have had a more team-oriented, multidisciplinary vision of this role from the very beginning. Since 2017, I have held a part-time position as a NP for one of the largest groups of Federally Qualified Health Centers (FQHC) health clinics for vulnerable populations in California. One of the Deputy Chief Medical Officers (CMO) oversees the project I am involved in, and is a a NP among a majority of MDs. My work has usually involved covering absences of other NPs and MDs remotely (interpreting results, prescribing medications, ordering exams such as X-rays or MRI as necessary, etc.) and developing protocols with the CMO.
However, since Covid-19 hit, we have upgraded to a more modern electronic health record (EHR) system, and this accelerated the work of all providers as we shifted towards providing telemedicine consultations. Recently, I have also been part of a Covid-19 team, monitoring the recent literature and helping to develop protocols. I am proud to work with an organization that helps to reduce health inequities, as massive Covid-19 testing and vaccination for all patients, regardless of health insurance status, has been a priority in partnership with the Innovative Genomics Institute (who run the University of California, Berkeley's clinical testing lab) .
The APN has a rich history in the US, and this role has developed in multiple countries to represent a significant healthcare provider who offers high-quality care and improved access to healthcare services. The WHO deemed 2020 to be the “Year of the Nurse and Midwife” in honor of the 200th anniversary of Florence Nightingale's birth. This past year has been both exciting and challenging for the nursing profession worldwide with the Covid-19 pandemic, despite the suffering and difficulties to overcome. If Florence Nightingale could have seen the evolution of nursing science and particularly advanced practice, I think she would have been proud of APNs around the world… From the US to France.■
1. International Council of Nurses. Guidelines on Advanced Practice Nursing, 2020. Accessed 01/18/21 from https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf (English) and https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_FR_WEB.pdf (French)
2. University of Rochester. A half century of nurse practitioners, 2015. Accessed 01/18/21 from http://www.rochester.edu/news/nurse-practitioner-history/
3. US Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2019. Brief Summary Results from the 2018 National Sample Survey of Registered Nurses, Rockville, Maryland. Accessed 21/01/2021 : https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/nssrn-summary-report.pdf
4. American Association of Nurse Practitioners (AANP). NP Fact Sheet. Accessed 01/18/21 from https://www.aanp.org/about/all-about-nps/np-fact-sheet
5. Laurant M et al. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005;18(2): CD001271.
6. Stanik-Hutt J, Newhouse R. The quality and effectiveness of care provided by Nurse Practitioners. JNP 2013:9(8).
7. Muench U et al. Medication adherence, costs, and ER visits of nurse practitioner and primary care physician patients: evidence from three cohorts of Medicare beneficiaries. Health Serv Res 2019:54(1):187-97.
8. National Organization of Nurse Practitioner Faculties (NONPF). Nurse Practitioner Core Competencies Content, 2014. Accessed 01/18/21 from https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/2014npcorecompscontentfinaln.pdf
9. American Association of Colleges of Nursing. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, 2008. Accessed 01/18/21 from https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/APRNReport.pdf
10. ICN Nurse Practitioner/Advanced Practice Nurse Network. Network History. 1992 to 2000. Accessed 01/18/21 from https://international.aanp.org/About/History
11. International Advanced Practice Nurse Ambassador Program. Accessed 01/18/21 from https://www.aanp.org/education/professional-funding-support/international-advanced-practice-nurse-ambassador-program
12. Johns Hopkins University & Medicine. Mortality Analyses. Accessed 21/01/21 from https://coronavirus.jhu.edu/data/mortality
13. Hu Y et al. Prevalence and severity of corona virus disease 2019 (COVID-19): A systematic review and meta-analysis. J Clin Virol 2020;127:104371.
14. American Academy of Nurse Practitioners (AANP). COVID-19 State Emergency Response: Temporarily Suspended and Waived Practice Agreement Requirements, updated 10/7/20. Accessed 11/14/20 from https://www.aanp.org/advocacy/state/covid-19-state-emergency-response-temporarily-suspended-and-waived-practice-agreement-requirements
15. Brimelow et al. The New York Times. Why Researchers Hope to Test High-Risk Groups in California. Published 5/18/20. Accessed 01/18/21 from https://www.nytimes.com/2020/05/18/us/california-testing-for-covid-coronavirus.html
G. Bonnel is a member of the International Council of Nurses, the AANP (United States) and the Ordre national des infirmiers (France).
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Figure 1. Loretta C. Ford, co-founder of the NP role, considered a “super-hero” (used with permission from Dr Ford) .
Figure 2. Nurse Practitioner core competencies .
Figure 3. Mortality in the 20 countries most affected by Covid-19 . Adapted from Johns Hopkins University & Medicine’s Mortality Analyses (21/01/2021 data).
Figure 4. COVID-19 State Emergency Response . Used with permission from AANP for illustration purposes only, not as a source of current information past 10/7/20.
|APN||Advanced practice nurse|
|APRN||Advanced practice registered nurse|
|CNM||Certified nurse midwife|
|CNS||Clinical nurse specialist|
|CRNA||Certified registered nurse anesthetist|
|DNP||Doctorate of nursing practice|
|FNP||Family nurse practitioner|
|MSN||Master of science in nursing|
|PhD||Doctor of philosophy|
|Certificationa||Number of NPs (%)|
|Adult – gerontology primary careb||7.8|
|Pédiatrics – primary careb||3.7|
|Adult – gerontology acute care||3.4|
|Psychiatric/mental health – Familyb||1.8|
|Hospice and palliative care||1.5|
a NPs may be certified in more than one area.
b Primary care focus.