The Robert Wood Johnson Foundation (RWJF) featured Maryland’s own nurse practitioner Andrea Brassard as a prime example of the growing importance of APRNs in its article, “APRNs a ‘Big Part of the Solution’ to the Primary Care Provider Shortage.” The piece detailed how APRNs can, in many situations, step in to fill the role of physicians, providing care that is just as effective and even more affordable.
For Maryland’s RNs, earning an MSN to become an APRN can fulfill career goals and ensure more financial stability. An MSN can also pave the road to nonclinical careers in upper-level management, administration, research, informatics and academia.
Maryland is a great state in which to earn APRN certification. In fact, Baltimore ranks in the top-10 cities nationwide for having the highest number of jobs, and highest average salaries for nurse-midwives. The Maryland Department of Labor, Licensing, and Regulation projects that jobs for RNs in all APRN roles will see positive growth through the ten-year period leading up to 2022, while publications like the RWJF indicate APRNs will play an important and growing role in primary care for the foreseeable future.
As of 2014 there were thousands of practicing APRNS throughout Maryland (US Department of Labor):
- 2,600 nurse practitioners earning an average annual salary of $93,020
- 243 nurse-midwives earning an average annual salary of $102,710
- 370 nurse anesthetists earning an average annual salary of $168,210
Compare these figures with Maryland’s registered nurses, who in 2014 numbered 47,790 and earned an average annual salary of $72,210
State Certification Requirements for the APRN Roles Recognized in Maryland
The Maryland Board of Nursing recognizes four APRN roles:
- Nurse Practitioner (NP or CRNP)
- Certified Nurse Midwife (CNM)
- Certified Registered Nurse Anesthetist (CRNA)
- Clinical Nurse Specialist (CNS), including Nurse Psychotherapist
Nurse practitioners and clinical nurse specialists further specialize by becoming educated and certified in a specific patient population focus (family-individual across the lifespan; adult-gerontology primary or acute care; neonatal; women’s health; psychiatric-mental health).
Maryland and compact-state RNs can become certified as APRNs once they:
- Complete a board-approved master’s or higher degree specific to their chosen APRN role and patient population focus
- Earn national certification in their particular APRN role from a board-recognized organization
Once students have graduated from a board-approved MSN program they can take the national certifying examination in their specific APRN role (and population focus if becoming an NP or CNS). Each examination for APRN role-specific certification is sponsored by a different national certifying organization. Certifying bodies recognized by the Maryland Board of Nursing as conferring the certification necessary for APRN certification in the state:
- Nurse Practitioners and Clinical Nurse Specialists – NPs and CNSs are certified by any one of a number of different national organizations, including:
- Nurse-Midwives – the American Midwifery Certification Board (AMCB) certifies nurse-midwives
- Nurse Anesthetists – the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) certifies nurse anesthetists
Earning a Master of Science in Nursing (MSN) in Maryland
As required education, MSN or master’s-certificate programs are the starting point for prospective APRNs in Maryland. State residents can increasingly choose from colleges and universities throughout the nation that offer MSN programs online. These programs are designed to accommodate nurses’ busy schedules so as to allow them to remain employed full-time while simultaneously completing their education. Schools also strive to develop local partnerships for the clinical segment of an online MSN so as to eliminate the need to travel for clinical sequences.
The Maryland Board of Nursing recognizes the following programs, listed here by APRN role with local programs in Maryland noted:
- Nurse Practitioner – list of board-recognized nurse practitioner programs nationwide, including the following programs in the cities of:
- Bethesda – Adult Psychiatric Mental Health, Family, Women’s Health
- Baltimore – Acute Care, Acute Care-Adult and Primary, Acute Care (blended with CNS), Acute/Critical Care, Adult, Adult and Gerontological Acute Care (blended with CNS), Adult and Gerontological Primary Care, Adult-Geriatric Acute Care, Critical Care and Emergency Nursing, Family, Gerontological, Neonatal, OB/GYN, Pediatric, Pediatric Acute Care, Pediatric Primary Care, Psychiatric Mental Health, Psychiatric Mental Health-Family Focus, Trauma
- Bowie – Family
- Salisbury – Family
- Clinical Nurse Specialist – the Maryland Board of Nursing recognizes programs accredited by the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN). The board may also consider graduate programs accredited by other organizations. Local CCNE and ACEN graduate programs can be found in the cities of:
- Nurse Anesthetist – the Maryland Board of Nursing recognizes graduate programs for this APRN role that are approved by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), including those in the cities of:
- Nurse-Midwife – the Maryland Board of Nursing recognizes graduate programs for this APRN role that are approved by the Accreditation Commission for Midwifery Education (ACME).
Maryland’s Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses
The following curriculum requirements were established by the Maryland Board of Nursing or national professional organizations as indicated:
All graduate-level NP programs that the Maryland Board of Nursing approves include coverage of the following subjects, both in didactic and clinical education:
- Nurse practitioner advanced topics and population-specific core competencies
- Physiology and pathophysiology
- Physical and health assessment
- Pharmacology (at least three semester credits)
- Diagnosis and management of health problems that are commonly encountered according to population focus
- Clinical decision making
- Health promotion/disease prevention
- Health teaching and counseling
- Clinical education – at least 500 hours
Clinical Nurse Specialist
The National Association of Clinical Nurse Specialists (NACNS) specifies that the CNS curriculum must include these aspects:
- It must be clearly aligned to address the care of a specific population, and align with state requirements as well as nationally-recognized core competencies
- It must be accredited by a nursing education organization that is recognized by the US Department of Education
- Students should have RN licenses throughout their studies
- The faculty-student ratio should be 1:1 or 1:2 during clinical segments
- Clinical courses must give students many opportunities to develop skills in key areas and meet the CSN/APRN licensure or certification requirements
- The clinical segment must include at least 500 supervised clinical hours
As the only board-approved organization offering national certification in nurse-midwifery, the Accreditation Commission for Midwifery Education (ACME) specifies that a nurse-midwife graduate curriculum must cover the following core competencies, both in didactic education and clinical segments:
- Professional responsibilities of nurse midwives and the components of midwifery care
- Gynecologic care, perimenopausal, postmenopausal and care for other periods
- Hallmarks of midwifery, including the promotion of family-centered care
- Management of common health problems
- Fundamentals of midwifery care
- Primary health care of women
- Midwifery management
- Childbearing family
- Newborn care
The clinical segment is usually completed in not less than 500 hours, and if nurse-midwives want to have prescriptive authority they must complete at least three semester credits in pharmacology.
As the only board-approved organization offering national certification for nurse anesthetists, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires a graduate program curriculum to include the following didactic elements:
- Pathophysiology, anatomy, and physiology – total 135 hours
- Concepts in chemistry and biochemistry, pharmacology of anesthetic agents and adjuvant drugs – total 105 hours
- Physics, pain management, equipment, technology, and basic-to-advanced principles of anesthesia practice – 105 hours total
- Professional aspects of the practice of nurse anesthesia – 45 hours
- Clinical correlation conferences – 45 hours
- Nurse anesthesia research – 30 hours
- Advanced physiology and pathophysiology
- Advanced healthcare assessment
- Ultrasound and radiology
- Advanced pharmacology
The clinical segment must include at least 2,000 hours of supervised training plus the study of at least 600 clinical cases.
Selecting the Right Type of Program Based on Current Education
Different types of MSN programs are designed to accommodate RNs based on the degree they currently hold:
- RNs with a Bachelor’s of Science in Nursing (BSN) can apply to conventional MSN programs, which take around two years to complete
- RNs with an Associate’s degree in nursing (ADN) can apply to RN-to-MSN bridge programs, which often result in a BSN along the way and take about three years for completion
- RNs with a Bachelor’s degree in an area other than nursing can apply to direct-entry MSN programs, completing any outstanding prerequisites and then moving on to core-MSN nursing subjects; these programs can take around three years to complete
Scope of Practice and Maryland State Laws Governing Advanced Practice Registered Nursing
Title 10, Subtitle 27 of the Code of Maryland Regulations (COMAR) contains the laws relating to advanced practice registered nurses. The scope of practice for the following APRN roles is clearly defined within these regulations by the Maryland Board of Nursing:
Scope of Practice for Nurse Practitioners
- Independent and comprehensive physical assessment of patients
- Examination of teenagers aged 15-17 to determine pregnancy
- Complete the date of birth and other information on a birth certificate
- In some cases, complete a death certificate
- Establish medical diagnosis for common short-term and chronic stable health problems
- Order, perform, and interpret lab tests
- Order and perform diagnostic, therapeutic, and corrective measures
- Prescribe drugs
- Provide emergency care
- Refer patients to physicians and other health care providers
- Only practice in the NP’s area of certified specialization
- All activities that fall under the purview of registered nurses
A psychiatric nurse practitioner working with a physician is permitted to do the following:
- Admit a minor to a facility for treatment of a mental disorder
- Admit an individual on an involuntary basis to a facility for treatment of a mental disorder
Scope of Practice for Clinical Nurse Specialists:
- Facilitate the continuous improvement of nursing care and patient outcomes
- Work within their core competencies as defined by their national certification organization
- Create therapeutic environments through system change and mentoring
- Practice with individual clients, families, groups, and populations of clients
- Develop evidence-based and caring practices
- Alleviate patient distress
- Respond to diversity
- Encourage ethical decisions
Nurse Psychotherapist CNS:
- Collection of data to comprehensively assess the client’s mental health
- Development and implementation of a plan of care
- Individual, group, and family psychotherapy
- Child psychotherapy
- Behavioral care
- Case management
- Care to prevent mental illness and disabilities
- Use advanced psychological knowledge to improve health status and functionality
- Prescriptive authority is not authorized
Scope of Practice for Nurse-Midwives:
- Independent management of clients which are appropriate to the nurse-midwife’s skill, educational preparations, and clinical practice guidelines, referring those who are out of this range to a physician
- Consult and collaborate with physicians or other health care providers as needed
- Keep a record of all cases attended
Scope of Practice for Nurse Anesthetists:
- Perioperative management and assessment of patients needing anesthesia services
- Administration of anesthesia
- Fluid management intravenously
- Respiratory care
- Refuse to perform any act if it is unsafe, involves an invalidly prescribed medication, or beyond a nurse anesthetist’s clinical skills
APRN Collaborative Agreements in Maryland
With the exception of nurse practitioners and nurse anesthetists, APRNs (clinical nurse specialists, and nurse-midwives) can practice independently in Maryland within their scopes of practice.
Nurse Practitioners – New nurse practitioners must indicate a mentor as part of their certification application. The mentor can be a physician or another experienced nurse practitioner, and will serve in this capacity for 18 months.
This recent mentorship law became effective in October 2015 and represents a step – and perhaps the final step – towards full independence for NPs in Maryland. Included as a nod to the lobbying efforts from the Maryland State Medical Society, which advocated that NPs should have a collaboration requirement, the mentor requirement thus far has been interpreted as a non-binding relationship between an NP and other medical professional. NPs are only required to identify a mentor by name on their application for APRN certification, and are not required to obtain any signatures.
The Maryland Board of Nursing has not yet specifically defined the role of a mentor. NPs can find more information about this developing regulation on the board’s APRN webpage, as well as through the Nurse Practitioner Association of Maryland.
Nurse Anesthetists – Nurse anesthetists must establish a collaborative agreement with an anesthesiologist, physician, or dentist, and indicate the name and license number of this person on their application for certification.
The Maryland Association of Nurse Anesthetists (MANA) has repeatedly called for this rule to be removed in line with the goal of establishing greater independence of practice and to better serve under-resourced rural areas. In November 2015 MANA proposed new legislation that would do just this.
In the meantime MANA has also called for the Maryland Board of Nursing to clarify its definition of collaboration. Nurse anesthetists can check on updates about this rule for collaboration through MANA or the state board.
Prescriptive Authority for APRNs in Maryland
Nurse practitioners and nurse-midwives are allowed to prescribe medications in Maryland within the following guidelines. They must also work with the Maryland Board of Nursing to establish a relationship with the Maryland Pharmacy Board. Prior to prescribing controlled substances they must register with the Drug Enforcement Administration (DEA).
- Can prescribe medications (including Schedules II-V) for patients at public and non-profit medical facilities, public/non-profit hospitals, public/non-profit clinics, university clinics/hospitals, and for patients in workers compensation programs
- Act within standard prescribing guidelines
- Maintain files of all prescriptions that have been written, with a separate file for Schedule II prescriptions
- Can prescribe starter doses of medications
- Can prescribe Schedule II-V substances
- When prescribing medications, the nurse-midwife must be at a public, non-profit, or public-supported health care facility
Independent Practice for APRNs in Maryland
Maryland has recently taken steps that allow its APRNs to move towards independent practice. This includes legislation passed in September 2014 that effectively allows for the complete independent practice of nurse-midwives, and legislation passed in October 2015 that allows a similar level of independence for nurse practitioners.
As of 2016, the Maryland Association of Nurse Anesthetists (MANA) has legislation pending that would remove the obligation for collaboration for this APRN role. Clinical nurse specialists can work independently within their scope of practice.
APRN Consensus Model in Maryland
The National Council of State Boards of Nursing (NCSBN) identifies Maryland as being on the right track towards the implementation of its consensus model, with additional room for improvement. The NCSBN developed its consensus model with the aims of:
- Standardizing APRN certification nationwide to give APRNs greater mobility between states
- Improve access to healthcare, especially in rural areas
- Improve the quality of healthcare
In addition to Maryland’s recent legislation affecting APRNs, the NCSBN also advocates granting full prescriptive authority to all APRNs, including clinical nurse specialists.
Continuing Education Requirements for APRNs in Maryland
All APRN certifications must be renewed at the same time as the traditional RN license. To be eligible for renewal, APRNs must maintain their specific national certification.
For nurse-midwives, because national certification is maintained on a five-year renewal cycle with the American Midwifery Certification Board (AMCB), each time a nurse-midwife renews their APRN certification with the Maryland Board of Nursing they must also show proof that they are enrolled in the AMCB’s Certification Maintenance Program.