Advanced Nurse Practitioner Education in
the USA;Past, Present and Future
Christopher Manacci, MSN, ACNP
The National Flight Nurse Academy
Frances Payne Bolton School of Nursing
Case Western Reserve University
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Discuss the definition and educational
requirements for becoming a Nurse
Practitioner
Understand the differences between Nurse
Practitioners and other providers.
Discuss the Acute Care Nurse Practitioner
scope of practice
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Late 1950’s-Ingles/
Stead
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1960-CNS
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Mid 1960’s-NP’s
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1990 ACNP
Historical Perspective
• 1970-Neonatal NP • 1997-Balanced
Budget Act
• Early 1990’s-NP
• 2000-CTP passed
required have
master’s degree
urban settings
• 1994-ACNP scope • 2002-Prescriptive
of practice
Authority fully
implemented
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Clinical Nurse Specialist
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Certified Nurse Midwife
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Certified Registered Nurse Anesthetist
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Certified Nurse Practitioner
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Registered nurses who:
◦ Are master’s or doctoral prepared
◦ Has become an expert clinician in a specialty area.
◦ National certification is optional.
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The functions of the CNS include clinician,
leader, educator, and change agent to
improve quality of care.
Ohio Association of Advanced Practice Nurses, 2001
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Registered nurses who:
◦ Have advanced training in Women’s health and
midwifery.
◦ Have a master’s degree and
◦ Are nationally certified
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The functions of the CNM include labor and
delivery, prenatal, postpartum, newborn and
routine gynecological care
Ohio Association of Advanced Practice Nurses, 2001
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Registered nurses who:
◦ Have critical care training
◦ Have a master’s degree in the delivery of
anesthesia
◦ Is nationally certified
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CRNA functions include: administration of
anesthetic agents/drugs for surgical,
diagnostic procedures, and acute and
chronic pain control
Ohio Association of Advanced Practice Nurses, 2001
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Registered nurses who:
◦ Have a master’s degree or doctorate
◦ Are nationally certified
◦ Have advanced training and education in a
specialized area of health care
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CNP functions include: management of
acute and chronic illnesses and disease
prevention to a variety of age ranges in a
variety of care settings
Ohio Association of Advanced Practice Nurses, 2001
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Neonatal nurse practitioner
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Family nurse practitioner
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Adult nurse practitioner
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Acute Care Nurse Practitioner
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Nurse Practitioner
◦ CNP works under his/her license
◦ Responsibility rests on competence of individual
◦ In collaborative arrangement, parties interact under
mutual respect and authority.
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Written guideline which defines
responsibilities, accountabilities, and
obligations of the specific CNP practice.
Limited by:
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State legislation
Standard Care Agreement
Credentialing institution
Collaborating Physician Scope of Practice
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Physician licensed to practice medicine in
Ohio who agrees to work with the Advanced
Practice Nurse in order to mutually establish a
procedure for patient care
Ohio State Board of Nursing, 2001
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Systematic formal guide for planning and
evaluating health care.
State of Ohio Board of Nursing, 2001
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Written agreement between CNP and
collaborating physician regarding guidelines
of care and scope of practice.
Nurse Practitioner
Clinical
Research
Educator
Consultant Administrator
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Rounds
H&P’s/discharges
Physical exams
Evaluation/initiation of
plan of care
◦ diagnostics
◦ pharmacotherapy
◦ multidisciplinary
collaboration
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Intubation
Line placement: central, Swan, arterial
Tube Thoracostomy
Wound Closure
Lumbar drain
Subdural drain removal
CSF specimens
C-spine clearance
Laceration repair
VP shunt reprogram
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Identify research opportunities
Collaborate to develop research study/design
Incorporate evidenced based practice
Identify quality/performance issues
Communicate specialty knowledge through
professional publications
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Prioritize patient/family learning needs
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Conduct formal/informal teaching
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Provide teaching to other health care
disciplines or community agencies as
requested
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Clinical resource and continuity
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Quality assurance involvement
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Multidisciplinary contact to assist with patient
flow/resource utilization
Formulary ACNP
Family/Adult
Approved for
intravenous:
Approval for oral/
may not prescribe IV:
• Inotropes
• Nitrates
• Antiarrhythmics
• Inotropes
• Nitrates
• Antiarrhythmics
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Vasodilators
Beta blockers
Antihypertensives
Vasopressors
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Vasodilators
Beta blockers
Antihypertensives
Vasopressors
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Blood
Plasma Expanders
Parenteral vitamins
Parenteral electrolytes
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Systemic alkalinizers
Anticoagulants
IV-Aminoglycosides
NSAIDS-prescription
Key elements of the acute care nurse
practitioner :
•Advanced clinical expertise
•Development of differential diagnoses
•Use of medical diagnostic reasoning to formulate the plan
of care
•Order and prescription of pharmacologic and nonpharmacologic therapy
Key elements of the acute care nurse
practitioner :
• Planning and management of patient care across the acute care
continuum
• Utilization and performance of invasive and non invasive
interventions and procedures to promote physiologic stability or
obtain diagnostic information
• Surveillance of care
• Accountability and authority for patient care outcomes across
settings and boundaries
Key elements of the acute care nurse practitioner:
• Evidence-and research-based clinical practice.
• Monitor, evaluate and refine care in a continuous fashion
• Accountability and authority for patient outcomes across
settings
• Clinical leadership
• Managing and negotiating health care delivery systems,
• Prevention and promotion of health
• Provide care for awareness of the uniqueness of the individual.
Formal Preparation
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Diagnostic reasoning
Advanced pharmacology
Invasive interventions
In keeping with the standards of the nursing
profession
Introducing graduate level academic preparation for
research and practice.
•Provide the highest level of care to those most in
need.
•Create a mechanism for the distribution of research
into clinical practice.
•Advance science and Nursing.
•Reduce cost by early intervention.
•Educate those already trained and meet today’s
societal needs.
Advanced Practice Model
Potential Revenue Stream
Funded Projects
Potential Revenue Stream
Consultation
Differential Diagnosis
Evaluation
Data Collection
Research
ROTOR
& Triage
Mobile
ICU
Transport
Response
ACNP
AMET
Global
Fixed
& Care
Wing
Response
Outcome
Evaluation
Mobilization
Resources
Prescriptive Plan / Intervention
Potential Revenue Stream
Clinical Mgt
The First University Degree Program
with Subspecialty in Flight Nursing
The Case Western Reserve University Frances Payne Bolton
School of Nursing, in collaboration with our clinical partners:
Louis Stokes Cleveland
VA Medical Center
Plan of Study;
Full-time study 48 semester hours
Synthetic Natural Environment
Headquartered at the Frances Payne Bolton School, the Flight
Nurse Academy features environmental and human simulators
for in-flight training.
Summer Camp
Synthetic Natural Environments
Human Simulation
Summer Camp
“Taking critical care from the bedside
to the roadside”