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Earning a Master of Science in Nursing (MSN) provides RNs with a foundation in advanced pathophysiology, health assessment, and pharmacology, allowing them to gain a greater level of respect and higher pay as advanced practitioners. RNs interested in moving into advanced nonclinical roles in higher education, nursing administration, informatics, patient advocacy and more, also pursue master’s degrees in nursing with specialty tracks in their area of interest.
California’s advanced practice registered nurses (APRNs) provide safe, effective, high quality care under strict certification laws that require them to earn a graduate degree and national certification in their particular APRN role and patient population focus.
APRNs in California continue to seek autonomy and the ability to practice independently without the need to maintain a collaborative agreement with a physician, even as proponents argue that independent practice would help offset the growing shortage of physicians in the state. Physician shortages, although nothing new to the state, have only increased in recent years since the implementation of the Affordable Care Act has helped millions more Californians gain access to health insurance.
The California Board of Registered Nursing (BRN) reported that more than 27,000 advanced practice registered nurses (APRNs) were actively certified in the state as of June 2015:
- Nurse Practitioners: 20,518 (furnishing: 16,521)
- Certified Nurse-Midwives: 1,279 (furnishing: 905)
- Clinical Nurse Specialists: 3,484
- Certified Registered Nurse Anesthetists: 2,300
State Certification Requirements for the APRN Roles Recognized by the California Board of Registered Nursing
The California Board of Registered Nursing (BRN), part of the Department of Consumer Affairs, certifies qualified RNs in one of four distinct advanced practice registered nurse (APRN) roles:
- Nurse Practitioner (NP)
- Nurse-Midwife (NM)
- Clinical Nurse Specialist (CNS)
- Nurse Anesthetist (NA)
California RNs with unrestricted licenses in good standing can become state certified through the BRN in one of these four roles by earning a Master of Science in Nursing (MSN) specific to their advanced practice role of choice and becoming nationally certified in that role.
Nurse practitioners and clinical nurse specialists further focus their education and become certified in a particular patient population focus (adult-gerontology; family/individual across the lifespan; neonatology; pediatrics; psychiatric/mental health; or women’s health). Nurse anesthetists are able to work with all patient population groups without the need for population-specific education and certification, while nurse-midwives work with women and newborns, as is implied by the definition of the role.
The BRN also certifies psychiatric/mental health nurses independent of the four APRN roles. Psychiatric/mental health nurses, like APRNs, must possess an MSN or higher.
The BRN recognizes the following national certifications in each APRN role and patient population focus as conferring the credentials RNs need to qualify for a state-issued APRN certificate:
Registered Nurse Practitioner (RNP)
- American Academy of Nurse Practitioners
- Adult Nurse Practitioner (ANP)
- Family Nurse Practitioner (FNP)
- Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP)
- American Nurses Credentialing Center
- Acute Care Nurse Practitioner-Board Certified (ACNP-BC)
- Adult Nurse Practitioner-Board Certified (ANP-BC)
- Adult Psychiatric-Mental Health Nurse Practitioner-Board Certified (PMHNP-BC)
- Adult-Gerontology Acute Care Nurse Practitioner-Board Certified (AGACNP-BC)
- Adult-Gerontology Primary Care Nurse Practitioner-Board Certified (AGPCNP-BC)
- Family Nurse Practitioner-Board Certified (FNP-BC)
- Gerontological Nurse Practitioner-Board Certified (GNP-BC)
- Pediatric Primary Care Nurse Practitioner-Board Certified (PPCNP-BC)
- Psychiatric-Mental Health Nurse Practitioner-Board Certified (PMHNP-BC)
- AACN Certification Corporation
- Acute Care Nurse Practitioner Adult-Gerontology (ACNPC-AG)
- Pediatric Nursing Certification Board
- Pediatric Nurse Practitioner Primary Care (CPNP-PC)
- Pediatric Nurse Practitioner Acute Care (CPNPAC)
- Pediatric Primary Care Mental Health Specialist (PMHS)
- National Certification Corporation
- Women’s Health Care Nurse Practitioner-Board Certified (WHNP-BC)
- Neonatal Nurse Practitioner-Board Certified (NNP-BC)
Clinical Nurse Specialist (CNS)
- AACN Certification Corporation
- Clinical Nurse Specialist; Wellness through Acute Care (Adult-Gerontology) (ACCNS-AG)
- Clinical Nurse Specialist; Wellness through Acute Care (Pediatric) (ACCNS-P)
- Clinical Nurse Specialist; Wellness through Acute Care (Neonatal) (ACCNS-N)
- American Nurses Credentialing Center
- Pediatric Clinical Nurse Specialist-Board Certified (PCNS-BC)
- Pediatric Clinical Nurse Specialist-Board Certified (PCNS-BC)
- Home Health Clinical Nurse Specialist-Board Certified (HHCNS-BC)
- Gerontological Clinical Nurse Specialist-Board Certified (GCNS-BC)
- Adult-Gerontology Clinical Nurse Specialist-Board Certified (AGCNS-BC)
- Adult Psychiatric-Mental Health Clinical Nurse Specialist-Board Certified (PMHCNS-BC)
- Adult Health Clinical Nurse Specialist-Board Certified (ACNS-BC)
- Oncology Nursing Certification Corporation
- Advanced Oncology Certified Clinical Nurse Specialist (AOCNS)
Certified Registered Nurse Anesthetist (CRNA)
- National Board of Certification and Recertification for Nurse Anesthetists
- Certified Registered Nurse Anesthetist (CRNA)
Certified Nurse-Midwife (CNM)
- American Midwifery Certification Board
- Certified in Nurse-Midwifery (CNM)
Earning a Master of Science in Nursing (MSN) in California
In addition to the many conventional campus-based graduate programs available in California, many nursing schools now offer fully accredited online programs that allow working RNs to complete didactic requirements through distance learning. Accredited online programs partner with hospitals throughout the nation in order to give graduate nursing students access to sites that support clinical training without the need to travel or relocate.
The BRN recognizes only nationally accredited APRN programs for initial licensure. These include:
Accreditation of Nurse Practitioner and Clinical Nurse Specialist Programs:
The Commission on Collegiate Nursing Education (CCNE) accredits nursing programs in the U.S. at all levels, including MSN degree programs and post-graduate APRN certificate programs. There are 34 CCNE-accredited programs in California, located in the following cities:
- Azusa
- Riverside
- Chico
- Carson
- Fresno
- Fullerton
- Long Beach
- Los Angeles
- Sacramento
- San Bernardino
- San Marcos
- Turlock
- Oakland
- Loma Linda
- San Diego
- Oakland
- San Francisco
- San Jose
- Chula Vista
- Irvine
- Costa Mesa
- Pomona
The Accreditation Commission for Education in Nursing (ACEN) accredits master’s degrees and post-master’s certificates in nursing. There is one ACEN-accredited program in California, located in Rohnert Park.
Accreditation of Nurse Anesthetist Programs:
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) accredits nurse anesthetist programs in the U.S. There are five COA-accredited programs in California, located in the following cities:
- Fresno
- Loma Linda
- Los Angeles
- Oakland
- Pasadena
Accreditation for Nurse-Midwife Programs:
The Accreditation Commission for Midwifery Education (ACME) accredits nurse-midwifery programs in the U.S. There are three ACME-accredited programs in California, located in the following cities:
- Fullerton
- San Diego
- San Francisco
California Board of Registered Nursing Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses
Graduate programs approved by the BRN must include the following as specified for each APRN role:
Clinical Nurse Specialist MSN Programs – To earn eligibility for certification as a CNS in California, RNs must complete an accredited advanced practice nursing program and at least 500 hours of clinical experience.
The National Association of Clinical Nurse Specialists oversees the National CNS Competency Task Force, which identifies all accredited programs as preparing students in the following competencies:
- Direct Care Competency
- Consultation Competency
- Systems Leadership Competency
- Collaboration Competency
- Coaching Competency
- Research Competency
- Ethical Decision-Making, Moral Agency and Advocacy Competency
Nurse-Midwife MSN Programs – According to the BRN, a program of study preparing nurse-midwives must:
- Have a primary purpose of preparing nurse-midwives
- Have objectives and a philosophy that describes the theoretical knowledge base and clinical competences expected of graduates
The curriculum of an accredited nurse-midwifery program must:
- Be at least 12 months in length
- Must contain (but is not limited to) the following content:
- Anatomy; physiology; obstetrics and gynecology; neonatology; child growth and development; nutrition; physical assessment; pharmacology; embryology and fetal development
- Concepts in psychosocial, emotional and cultural aspects of maternal and child care; breastfeeding; family planning; community health; principles of preventive health
- Aspects of the management of normal pregnancy, labor and delivery, routine gynecological care in alternative birth centers, home, and hospitals, newborn care
The nurse-midwifery program must also:
- Provide concurrent theory and clinical practice in settings in the U.S.
- Include the nurse-midwifery management process
- Prepare nurse-midwives to practice in areas such as:
- Management of the normal pregnancy
- Management of normal labor and delivery in all birth settings
- Management of the normal postpartum period
- Management of normal newborn care
- Management of family planning and/or routine gynecological care
Nurse Practitioner MSN Programs – A BRN-recognized nurse practitioner program must:
- Have a primary purpose of preparing RNs who can provide primary healthcare
- Have a clearly defined philosophy in written form
- Have objectives that reflect the program’s philosophy
The curriculum must:
- Include all theoretical and clinical instruction to prepare graduates to provide primary healthcare
- Provide training in an area of specialization broad enough to detect and control presenting symptoms and minimize the potential for disease progression
- Be at least 30 semester units that includes both theory and supervised clinical practice
The curriculum must include (but is not limited to):
- Normal growth and development
- Comprehensive physical examination
- Maintaining a developmental health history
- Pathophysiology
- Communication skills
- Psycho-social assessment
- Disease management
- Principles of health maintenance
- Nutrition
- Nurse practitioner role development
- Assessment of community resources
- Healthcare delivery systems
Nurse Anesthetist MSN Programs – The BRN recognizes accredited nurse anesthesia programs that have met the standards of the Council on Accreditation of Nurse Anesthesia Education Programs and Schools.
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires the academic curriculum and prerequisite courses of nurse anesthesia programs to include:
- Anatomy, physiology, and pathophysiology (135 hours)
- Basic and advanced anesthesia practices (105 hours)
- Professional aspects of nurse anesthesia practice (45 hours)
- Pharmacology of anesthetic agents and adjuvant drugs within the concepts of biochemistry and chemistry (105 hours)
- Research (30 hours)
- Clinical conferences (45 hours)
- Radiology and ultrasound
Selecting the Right Program Based on Current Education
Master’s programs are offered in a number of different formats meant to accommodate RNs with either an associate’s degree in nursing or a bachelor’s degree in nursing, as well as bachelor’s-educated professionals from a non-nursing background:
- Traditional Terminal MSN Programs accommodate RNs who already hold a BSN. These programs take about two years to complete.
- RN-to-MSN Programs are designed to accommodate RNs who possess an associate’s degree in nursing. RN-to-MSN programs (often called bridge programs) result in both a BSN and MSN and take about three years to complete.
- Entry-level MSN Programs (also often called direct-entry programs) are designed for non-nursing professionals that possess a bachelor’s degree in an area other than nursing. These accelerated programs take into account a student’s previous education in nursing prerequisites and result in a BSN, RN license and MSN.
Scope of Practice and California State Laws Governing Advanced Practice Registered Nursing
California’s APRNs continue to fight for autonomy, as recommended in the APRN Consensus Model, created by the National Council of State Boards of Nursing’s (NCSBN) with input from more than 40 other nursing associations, certifying bodies and program accreditation agencies.
In June 2015, Senate Bill 323 fell on deaf ears, as an Assembly committee voted against allowing nurse practitioners to work independently without doctor’s supervision while under contract with a medical group. The California Association of Nurse Practitioners supported the bill and continues to work toward allowing NPs in California to practice independently to the full extent of their training and education.
As of 2016, the California Board of Registered Nursing (BRN) defines the scope of practice for each APRN role as follows:
Clinical Nurse Specialist Scope of Practice
CNSs must adhere to five components of competency:
- Expert Clinical Practice
- Works with staff to improve clinical care
- Assesses and intervenes in complex healthcare problems
- Manages populations of clients
- Precepts students and mentors other nursing staff
- Education
- Assists with and promotes staff development
- Provides formal education classes
- Services as preceptor to nursing students, new RN graduates, and RNs reentering the workforce
- Mentors and coaches staff and students
- Research
- Uses clinical inquiry and research in an advanced specialty area of practice
- Initiates research into topics that impact nursing care
- Publishes data from research topics related to the specialty area of practice
- Consultation
- Consults in multiple healthcare settings
- Makes recommendations to physicians, patients, healthcare organizations, insurance companies, and other healthcare providers
- Evaluates policy and procedures for clinical practice
- Uses evidence-based clinical practice to improve patient care and patient outcomes
- Clinical Leadership
- Uses theory and research for clinical leadership
- Serves as a change agent in healthcare settings
- Serves in a leadership role in the community
Nurse-Midwife Scope of Practice
The nurse-midwife scope of practice includes:
- Providing supervision, care, and advice in a variety of settings to women during the antepartum, intrapartum, postpartum, and interconceptional periods, and family planning needs
- Obtaining physician assistance/consultation when indicated
- Providing emergency care until physician assistance can be obtained
- Conducting deliveries and caring for the newborn and infant
- Other practices and procedures when the nurse-midwife and supervision physician deem appropriate
Nurse Practitioner Scope of Practice
The nurse practitioner possesses educational preparation and skills in physical diagnosis, psychosocial assessment, and the management of health-illness needs in primary care. Nurse practitioners do not have an additional scope of practice beyond the usual RN scope and must therefore rely on standardized procedures for authorization to perform overlapping medical functions.
Nurse practitioners also provide authority for nursing functions essential to providing primary healthcare that do not require standardized procedures, such as physical and mental assessment, disease prevention, and restorative measures. They also have the authority to initiate emergency procedures.
Nurse Anesthetist Scope of Practice
The BRN defers the scope of practice of California nurse anesthetist to national standards. The BRN will only develop new standards if there is a public safety need for standards more stringent than the councils’ standards. The American Association of Nurse Anesthetists (AANA) outlines the standards in the Scope of Nurse Anesthesia Practice:
Certified Registered Nurse Anesthetists (CRNAs) practice both autonomously and in collaboration with many health providers. They care for patients at all acuity levels across the lifespan and in a variety of settings, including (but not limited to):
- Diagnostic
- Obstetrical
- Pain management
- Surgical
- Therapeutic
The practice of nurse anesthesia care includes (but is not limited to):
- Conducting pre-anesthesia evaluations
- Developing a patient plan of care
- Obtaining formal consent for anesthesia
- Ordering/prescribing/selecting drugs and controlled substances
- Performing patient histories and physicals
- Selecting and inserting monitoring modalities
Prescriptive Authority and Collaborative Practice for Nurse Practitioners and Nurse-Midwives
Certified NPs and NMs in California may apply for and obtain a furnishing number to furnish drugs and medical devices. Nurse practitioners and nurse-midwives authorized to furnish or issue drug orders for controlled substances (Schedules II through V) must register with the DEA.
Candidates for a BRN furnishing number must first complete an approved pharmacology course completed at a nationally accredited master’s or post-master’s level academic APRN program.
The certificate to practice as an NP or NM authorizes the APRN, under the supervision of a licensed physician, to perform all duties within the scope of their practice. Any devices or drugs furnished or ordered by NPs or NMs must be used in accordance with standardized procedures or protocols developed and approved by the supervising physician, the NP/NM, and the facility administrator.
Schedule II controlled substance protocols and procedures must address the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is furnished.
Physician/surgeon supervision does not require the physical presence of a physician, but does include:
- Collaboration on the development of the standardized procedures or protocols
- Approval of the standardized procedures or protocols
- Availability of the physician or surgeon by telephone at the time of patient examination