EMERGENCY NURSES ASSOCIATION
WHITE PAPER
ADVANCED PRACTICE IN EMERGENCY NURSING
Advanced practice nurse (APN) is the broad term used to identify the advanced practice roles of:
• Certified registered nurse anesthetists (CRNAs);
• Certified nurse midwives (CNMs);
• Clinical nurse specialists (CNSs); and
• Nurse practitioners (NPs).
The American Nurses Association (ANA) defines an advanced practice registered nurse as a
registered nurse who has acquired advanced specialized clinical knowledge and skills to provide
health care.1 According to the ANA, all APNs practice from both specialized and expanded
knowledge and skills.2 Specialized knowledge refers to the concentration of one’s focus to part
of the whole field of professional nursing.2 Expanded knowledge is defined as new practice
knowledge and skills, including the knowledge and skills that authorize role autonomy within
areas of practice that may overlap traditional boundaries of medical practice.2 A central
competency of all advanced practice nursing roles is direct clinical practice.3,4 APNs are
expected to hold a masters degree or a doctorate.1
The Emergency Nurses Association (ENA) defines an advanced practice registered nurse as a
registered nurse who has completed a graduate degree in a specialty area of nursing and has a
direct and/or indirect clinical practice in the specialty area. The advanced practice registered
nurse “… is prepared to assume responsibility and accountability for health promotion and the
assessment, diagnosis, and management of patient problems which [may include] the use and
prescription of pharmacologic and non-pharmacologic interventions.”5 Advanced practice
registered nurses are seen not only as clinical patient care experts, but the expanded roles of
advanced practice registered nurses involve leadership, administration, consultation, education,
and research.6
According to the American Academy of Nurse Practitioners, “advanced practice nurses make
independent and collaborative health care decisions. They are expert clinicians engaged in active
clinical practice. The advanced practice nurse demonstrates leadership as a consultant, educator,
administrator, and researcher. An important leadership function of all advanced practice nurses is
participation in legislative and professional activities to promote professional advancement and
health related social policies.”7
This position statement will focus on the roles of the CNS and the NP. This statement will
further delineate these roles for APNs in emergency care settings.
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Clinical Nurse Specialists
CNSs are licensed registered nurses who have graduate preparation (masters or doctorate) in
nursing as a Clinical Nurse Specialist. CNSs are expert clinicians in a specialized area of nursing
practice. The specialty may be identified in terms of a population (e.g., pediatrics, geriatrics,
women’s health), setting (e.g., critical care, emergency), disease or medical subspecialty (e.g.,
diabetes, oncology), type of care (e.g., psychiatric, rehabilitation), and/or type of problem (e.g.,
pain, wounds, stress). CNSs practice in a wide variety of health care settings. In addition to
providing direct patient care, CNSs influence care outcomes by providing expert consultation for
nursing staff and by implementing improvements in health care delivery systems. CNS practice
integrates nursing practice, which focuses on assisting patients in the prevention or management
of illness, with medical diagnosis and treatment of disease, injury, and disability.
Nurse Practitioners
NPs are unique health care providers within the constellation of advanced practice nurses. Nurse
practitioners engage in advanced practice in a variety of specialty areas, such as emergency,
family, adult, pediatric, gerontological, women's health, school health, occupational health,
neonatal, and acute care. Nurse practitioners assess both medical and nursing problems. Their
practice emphasizes health promotion maintenance, disease prevention, and the diagnosis and
management of acute and chronic diseases. This includes taking histories; conducting physical
examinations; ordering, supervising, performing, and interpreting appropriate diagnostic and
laboratory tests; and prescription of pharmacological agents, treatments, and nonpharmacological therapies for the management of the conditions they diagnose. The nurse
practitioner serves as a primary care or specialty care provider and as a consultant for
individuals, families, and communities in a variety of ambulatory and inpatient settings.
CNSs and NPs in the United States have been recognized as advanced practice registered nurses
since the mid 20th century and have held APRN roles in emergency care settings for over four
decades.2,8 “Clinical nurse specialists were the first group to be recognized as advanced practice
registered nurses who have a unique body of knowledge and competencies based on education at
the graduate level. This body of knowledge and subsequent competencies distinguish CNSs from
the other three advanced practice groups.”9,10 Consistent with the National Association of
Clinical Nurse Specialists’ statement on clinical nurse specialist practice and education, the roles of
the clinical nurse specialist are described on the basis of three spheres of influence: (1) patient and
patient’s family, (2) nurse to nurse, and (3) system needs. Clinical nurse specialists’ roles include
clinical practice, education, research, leadership, and consultation.11 Practice and educational
core competencies for clinical nurse specialists have been developed by the National Association
of Clinical Nurse Specialists. The Emergency Nurses Association is developing the scope and
standards for clinical nurse specialists in emergency care settings.
Nurse practitioners providing care have recognized core competencies but none that are specific to
emergency care. Competencies are defined by the extent an individual can clinically manage
various situations that arise in that area of practice. The Emergency Nurses Association is
developing core competencies for nurse practitioners practicing in emergency care settings.
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Advanced practice registered nurses working in emergency settings are experienced providers. In a
survey of 166 advanced practice registered nurses who worked in emergency departments,
approximately two-thirds (63%) of the respondents were nurse practitioners, 28% were clinical
nurse specialists, and 9% were both nurse practitioners and clinical nurse specialists.8 The
respondents had practiced professional nursing for about 15 years before becoming advanced
practice registered nurses, and most had worked as an advanced practice registered nurse in the
emergency department for more than 5 years.8 Currently, there are no national specialty
certifications for nurse practitioners or clinical nurse specialists practicing in emergency care
settings; however, many advanced practice registered nurses hold a national certification for
practice as a nurse practitioner or clinical nurse specialist. Advanced practice registered nurses in
emergency settings reported being certified most often as family nurse practitioners (43%), acute
care nurse practitioners (13%), adult care nurse practitioners (12%), pediatric nurse practitioners
(7%), women’s health nurse practitioners (<1%), critical care clinical nurse specialists (9%),
medical-surgical clinical nurse specialists (5%), pediatric clinical nurse specialists (<1%), and
other clinical nurse specialists (10%).8
REFERENCES
1. American Nurses Association. (2004). Scope and standards of advanced practice
registered nursing. Washington, DC: Author.
2. American Nurses Association. (2003). Nursing's social policy statement (2nd ed.).
Washington, DC: Author.
3. Fawcett, J., Newman, D. M., & McAllister, M. (2004). Advanced practice nursing and
conceptual models of nursing. Nursing Science Quarterly, 17, 135-138.
4. Hamric, A. B. (2005). A definition of advanced practice nursing. In A. B. Hamric, J. A.
Spross & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach (3rd
ed., pp. 85-108). St. Louis, MO: Elsevier Saunders.
5. American Association of Colleges of Nursing. (2006, May 24). Advanced Practice
Nursing Consensus Work Group Report, May 2006 (Draft report from May 24, 2006
APRN Consensus Work Group meeting). Washington, DC: Author.
6. Chan, G. K. & Garbez, R. O. (2006). Education of advanced practice nurses for
emergency care settings: Emphasizing shared competencies and domains. Advanced
Emergency Nursing Journal, 28, 216-225.
7. American Academy of Nurse Practitioners. (2002). Nurse practitioners as an
advanced practice nurse role position statement. Austin, TX: Author. Retrieved
March 9, 2007, from
http://www.aanp.org/Publications/AANP+Position+Statements/Position+Statement
s+and+Papers.asp
8. Cole, F.L., Kuensting, L., MacLean, S.L., Abel, C., Mickanin, J., Eckhardt, P.,
Wilson, M., & Rehwaldt, M. (2002). Advanced practice nurses in emergency care
settings: A demographic profile. Journal of Emergency Nursing, 28, 414-419.
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9. Mick, D. J., & Ackerman, M. H. (2002). Deconstructing the myth of the advanced
practice blended role: Support for role divergence. Heart and Lung, 31, 393-398.
10. National Association of Clinical Nurse Specialists. (2005, July). White paper on
certification of clinical nurse specialists. Harrisburg, PA: Author.
11. National Association of Clinical Nurse Specialists. (2004). Statement on clinical
nurse specialist practice and education (2nd ed.). Harrisburg, PA: Author.
© Emergency Nurses Association, 2007.
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