APRN and PA Overview
From the patient perspective, the roles of the APRN and PA within a sleep center can be quite similar; their educational programs prepare them to provide clinical assessment, diagnosis, and treatment of patients. However, the scope of practice of the NP versus PA in the clinical setting may be affected by differences in educational backgrounds, state licensure, physician oversight, prescriptive authority, and reimbursement issues.
The term, APRN, refers to nurses with specialized training for providing direct care to individuals at an advanced level.9 APRNs are categorized into 4 groups, the clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), and nurse practitioner (NP). NPs are the most common sub-group of APRNs.4 Although the terms, NP and APRN, often are used interchangeably, this use is incorrect; all NPs are APRNs, but not all APRNs are NPs. There is some historical overlap, however variations exist between CNSs and NPs, particularly related to education and training in pharmacology, diagnosis, and treatment. Because of these differences, NPs generally have prescriptive authority while CNSs do not. Specialties for NPs often are determined by population (eg: adults) or work environment (eg: acute care).10 Examples of specialties that may be seen within sleep practices include Acute Care NP (ACNP), Adult NP (ANP), Family Practice NP (FNP), Pediatric NP (PNP), and Psychiatric/Mental Health NP (PMHNP).10 National efforts are underway to standardize APRN educational requirements, professional titles, areas of clinical practice, and state regulation.9
NP programs generally focus on a specific population (eg: pediatrics or adults), with the exception of training for FNPs which covers the lifespan. The NP clinical setting is determined by the area of specialty and may either focus on one setting (eg: outpatient) or multiple settings. PA educational programs include various clinical environments in both inpatient and outpatient settings for all age ranges.
Educational programs for APRNs are typically a blend of nursing and medical models, while PA programs are based exclusively on a medical model. The undergraduate education for APRNs prepares them for licensure as a registered nurse while the undergraduate education for PAs is typically in a health-related field. In general, NPs and PAs can perform health histories and physical examinations, order and interpret appropriate testing for further assessment and develop a treatment plan for patients with common health problems. Basic tests, such as laboratory testing, can be interpreted by a PA or NP. In certain clinical settings, other testing such as electrocardiography or x-rays may also may be reviewed or interpreted by a NP or PA. Additionally, any testing, which includes a physician review and interpretation, may be utilized in their assessments (eg: sleep studies). APRNs and PAs can prescribe therapeutics including pharmacologic agents and durable medical equipment. The extent of APRN and PA formal education in pharmacology and prescribing can affect state legislation regarding the degree of prescriptive authority. Within the sleep specialty, controlled-substance prescribing is a commonly encountered prescriptive limitation resulting from either state- or federal-level regulation relating to the scheduled classification of the medication.11
Any drug that utilizes a central pharmacy (eg: sodium oxybate) must adhere to prescribing and dispensing rules for the state in which the central pharmacy is located, affecting prescribing by a provider when practicing in other states if the rules differ.
APRN organizations and the American Association of Colleges of Nursing have recommended that the doctoral degree (either a Doctorate in Philosophy [PhD] or Doctorate of Nursing Practice [DNP]) be the minimum level of education required for certification by 2015.9,12 The PhD provides preparation with a focus on research while the DNP provides a clinically focused doctoral degree, focusing on evidence-based advanced nursing practice. PA programs have a target date of 2020 to award a master's degree as the minimum level of education to maintain national program accreditation.13 The American Academy of Nurse Practitioners (AANP) estimates that 98% of their members surveyed have a graduate degree and 14.6% have a doctoral degree (AANP personal communication).14 The American Academy of Physician Assistants estimates that 72% of clinically practicing PAs have a master's degree, 5% have a doctoral degree or a graduate certificate, and 20% have a bachelor's degree.15
Many factors besides educational background influence the scope of practice for APRNs and PAs.9,16 State “licensure” is probably the most obvious determinant with wide variation; some states choose to narrowly define scope of practice, while others approach it broadly. In some states, the authorization to practice does not come through licensure, but rather through other regulatory processes referred to as recognition, registration, or certification.9,16 In general, PA oversight is through the state medical board17 while APRN oversight is by the board of nursing.9 State oversight may include medication prescribing, restricted geographic location, and physician supervision or collaboration with APRN and PA practice.9,16 Additionally, state educational requirements ultimately determine what the minimum degree is for practice recognition within a state. APRN practice models can vary from independent practices to physician-collaborative practices while PA practices require physician supervision. State and federal regulatory agencies also can influence APRN and PA practices through their policies on controlled-substances prescribing, ordering therapeutic devices such as durable medical equipment and reimbursement of services.11,18,19 Employer or healthcare facilities further can influence the APRN or PA scopes of practice through internal policies.
As part of the licensure process, each state board determines the minimum standard for formal educational preparation and whether or not national certification is required to practice within the state. For APRNs, the majority of states require graduate- level education and/or national certification to practice20,21 while a small number of states require master's-level education as a minimum requirement for practice as a PA.22
Both APRNs and PAs have national organizations that determine standards for competency and educational preparation.13,23 PAs have one examination,24 whereas, NPs take specialty-specific certification examinations.10 Both disciplines require maintenance of a clinical practice and the completion of continuing education and professional-development activities for recertification. PAs and APRNs are allowed to use physician-level credits to meet their continuing education requirements; although, APRNs may need a portion of their credits to be earned from approved nursing organizations at an advanced practice level.10,25
There are a growing number of post-graduation PA-residency training programs, primarily in emergency medicine and surgery, and PAs can take optional specialty certification exams offered by the National Commission on Certification of Physician Assistants.25 In addition, both APRNs and PAs may be eligible for subspecialty certifications that reflect advanced levels of preparation (eg: advanced diabetes management certification)26 or more general levels of preparation (eg: asthma educator)27 administered by multidisciplinary professional organizations.
No formal training or certification in sleep medicine currently exists for APRNs or PAs. As the push towards formal education and greater specialty training increases, having specialty certifications in sleep for APRNs and PAs may become desirable; anecdotal reports suggest that some state boards are requesting additional proof of knowledge (continuing education) and competency in cases in which APRNs and PAs hold positions that exceed the education and training obtained during their initial formal education (eg: a family nurse practitioner working in a sleep center).
Finally, the terminology used to refer to these professional groups can be confusing to other disciplines. For example, there are a number of terms used to identify APRNs and PAs as one group. The Drug Enforcement Agency (DEA) uses the term mid-level provider (MLP), The Centers for Medicare and Medicaid (CMS) uses the term non-physician practitioner (NPP), but there is no term that has been defined and supported by both APRN and PA professional organizations. Although the term Advanced Practice Nurse (APN) has been used by some healthcare professionals to refer to an APRN, Advance Practice Registered Nurse is the term endorsed by the APRN consensus statement9 and the recent Institute of Medicine report.28