A Look Back at Advanced Practice Registered Nursing

By Maureen Schaupp, Associate Chief Nursing Officer, Advanced Practice Nursing, Nursing Quality and Practice

Advanced practice nursing has become a highly desirable career. At Cleveland Clinic, the number of advanced practice registered nurses (APRNs) has grown from 450 in 2009 to nearly 2,400 today. Nationally, the Bureau of Labor Statistics predicts a 45% growth of APRNs between 2019 and 2029, which is a higher percentage than the average for all occupations.

APRNs are extremely valuable to today’s healthcare system. They hold critical roles in addressing the rise in chronic medical conditions, expanding access to healthcare and meeting population health needs, especially for aging or underserved populations.

The move toward advanced practice nursing first gained momentum in the 1990s, although the informal role of the APRN can be dated to the earliest days of the nursing profession. The first nurse to provide patients with anesthetics did so in 1861 during the Civil War.

As the need for APRN’s expands, it can be helpful to look back at how the profession was established within the nursing ranks at Cleveland Clinic.

Laying the foundation

Advanced practice nurses were first united at Cleveland Clinic in 1999 when the Office of Advanced Practice Nursing was established. The office provided resources, offered education, promoted the appropriate use of APRNs and ensured adherence to the rules and regulations of the Ohio Board of Nursing and other regulatory agencies.

By 2010, a national trend was emerging for health systems to better leverage the skill and practice ability of APRNs. It was driven by:

• the passing of the Affordable Care Act, which introduced millions more Americans into the healthcare system.
• the introduction of population health.
• the release of the Institute of Medicine report on the future of nursing, which stated that:
  • APRNs needed to practice to the fullest extent of their education and training.
  • states were to reform scope-of-practice regulations and remove barriers to practice.

As patient volumes and the demand for advanced care providers increased, Cleveland Clinic leaders worked to create a new advanced practice nursing model. It was integrated into the organization’s team-based approach to care and designed to meet the current and future needs of healthcare.

A new operational model and structure

With more than 1,000 APRNs in 2016, Cleveland Clinic was the largest employer of APRNs in Ohio and one of the largest in the country. That year, the health system named its first Associate Chief Nursing Officer for Advanced Practice Registered Nursing and created an advanced practice provider governance structure to which all APRNs and physician assistants (PAs) reported. It also:

• aligned shared governance leadership with like roles already in place in the healthcare system
  (e.g., APRN coordinator, APRN manager, APRN director).
• launched an APRN productivity dashboard to create transparent and structured communication.
• integrated delineation of privileges for all APRN roles.
• established standard productivity metrics and integrated quality monitoring and safety standards.

Training and support

Cleveland Clinic established a 12-month APRN/PA onboarding program called Transition to Practice to further train advanced practice providers (clinically and didactically) to transition into clinical decision-making roles. It focused on refining the skills and knowledge of new graduates as well as experienced providers who were changing specialty areas.

Other APRN education, training and support initiatives included:

• providing ongoing education and resources (e.g., pharmacology education courses/reference materials, new APRN orientation).
• creating an APRN career coaching program.
• offering preceptor workshops (e.g., training APRNs on adult learning principles to better work with students).
• offering APRN students clinical experience.
• implementing an APRN online journal club to explore best practices.
• holding special events for education, including topics such as reimbursement and law.
• establishing a plan to integrate and support ongoing credentialing and privileging.

Between 2011 and 2020, advanced practice nurses in Ohio obtained the ability to prescribe Schedule II medications, but with an exclusionary formulary. The Certificate of Authority and Certificate to Prescribe were aligned with APRN licensing and the title of APRN was officially adopted.

Driving work forward

When the Office of Advanced Practice Nursing was formed in 1999, an APRN Council was also created. Today the council aims to promote professional practice, advocacy, recognition and support.

One of the council’s newest initiatives is the APRN Professional Development Pathways Program. It’s a year-long program that coordinates, enhances and facilitates APRNs’ portfolios and professional development. Participants select a key domain that aligns with their planned career path: research, leadership, education or quality. In 2019, the council also established a preceptor committee to support the education and resource efforts APRNs contribute to local graduate nursing students.

To date, Cleveland Clinic APRNs have provided more than 100,000 clinical hours in support of students from more than 60 schools.