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A specialized Master of Science in Nursing (MSN) provides the educational foundation RNs need to enter advanced practice, which comes with a greater level of autonomy, a great deal of respect in the professional community and the opportunity to earn a much higher salary. Between 1999 and 2014 the number of advanced practice registered nurses (APRNs) in Massachusetts almost doubled from 5,865 to 10,352. As of fiscal year 2014 the number of APRNs in Massachusetts licensed to practice in each role were as follows:
- 7,752 nurse practitioners
- 1,252 nurse anesthetists
- 868 psychiatric clinical nurse specialists
- 480 nurse-midwives
According to the US Department of Labor, Massachusetts’ APRNs rank nationally (2014):
- Massachusetts ranks fifth in the nation as having the most nurse practitioner jobs and highest average annual salaries ($107,230)
- Massachusetts ranks third in the nation for having the most nurse-midwife jobs, and sixth for having the highest average annual salaries ($103,600)
- Massachusetts’s nurse anesthetists are among the best paid in the nation, earning an average annual salary of $136,290 as of 2014
Boston.com ran an article in May 2013 that identified nurses – and especially highly skilled nurses – as being in strong and rising demand going into the future. In fact, the article identified this occupation as being projected to experience more growth than any other occupation. It attributed the rising need for APRNs as being due to the growing gap between the demand for healthcare services and the supply of highly qualified medical professionals. It also reported that employers were offering tuition reimbursement, signing bonuses, and student loan repayments to qualified applicants.
Licensing Requirements for the APRN Roles Recognized in Massachusetts
The Massachusetts Board of Registration in Nursing, a part of Health and Human Services’ Division of Health Professions Licensure, is responsible for licensing qualified registered nurses in the five APRN roles recognized in the state:
- Certified Nurse Practitioner (CNP)
- Certified Nurse-Midwife (CNM)
- Certified Registered Nurse Anesthetist (CRNA)
- Clinical Nurse Specialist (CNS)
- Psychiatric Clinical Nurse Specialist (PCNS)
Nurse practitioners and clinical nurse specialists can 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).
The board entrusts Professional Credential Services (PCS) to process APRN licensure applications. To be eligible for an APRN license, candidates must meet these basic requirements:
- Have a Massachusetts RN license and be of good moral character
- Complete a graduate program specific to an APRN role, and population focus as applicable
- Become certified in an APRN role and population focus through a board-approved national certifying body
- APRNs who care for patients directly must have professional malpractice liability insurance with coverage of at least $100,000 per claim and a minimum aggregate amount of at least $300,000
For the purpose of APRN licensing, the Massachusetts Board of Registration in Nursing recognizes national certification agencies for specific APRN roles that fall within these guidelines:
- Their scope is national
- They establish and maintain certification examinations that are consistent with national standards
- They establish and maintain educational eligibility requirements that are consistent with the requirements for APRN clinical categories of practice
- They have standardized methodologies in line with job analysis studies
- They establish principles for conflict resolutions
- The certification examination evaluates the entry-level practice capabilities of the APRN candidate
- The exam is regularly evaluated for accuracy, bias, and validity
- The exam meets nationally recognized accreditation standards
Board-recognized national certifying organizations are listed here with the corresponding APRN roles they certify:
- Nurse Practitioners and Clinical Nurse Specialists – these APRN roles are certified by many 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
While Massachusetts is not a member of the compact states licensure agreement, it does allow for APRN licensure via reciprocity for candidates who had to meet equivalent requirements to gain an APRN license in their home state. Reciprocity is considered on a case-by-case basis.
In addition to being the minimum requirement for an APRN license, an MSN degree is also an important qualification for RNs who want to advance into mid to upper-level academic, management, and administration careers.
Earning an Master of Science in Nursing (MSN) in Massachusetts
Holding an MSN that focuses on a particular APRN role is the minimum education requirement established by the Massachusetts Board of Registration in Nursing.
The state is home to seven board-approved MSN programs, which can be found in the cities of:
- Chester Hill
- Boston (three programs)
- Weston
- Salem
- Worcester
In addition to these programs, Massachusetts residents can also choose from a growing number of accredited MSN programs that are offered online by schools throughout the nation. These allow students to complete their education while maintaining a busy work schedule. Graduate schools work to place students in local facilities throughout Massachusetts for the clinical segment of the MSN program so there is no need to travel.
When choosing an MSN program, prospective APRN students should be aware of the standards the Massachusetts Board of Registration in Nursing looks for in MSN curriculum. To start, it only recognizes APRN graduate programs that include APRN core content in:
- Advanced assessment
- Advanced pathophysiology
- Advanced pharmacology
In addition, the Board has established the following criteria as defining an MSN accrediting agency that would meet its standards for program approval:
- It must maintain rigorous standards that prove it is a reliable accrediting agency
- It must maintain effective tools to continually evaluate an accredited program’s compliance with recognized standards
- It must be able to provide a detailed description of how it surveys an accredited program
- It must maintain and manage data about its analysis of accredited programs
- It must have procedures for responding to and investigating complaints
- It must update its policies and procedures for removing its accreditation status, and have a way of informing the board about this
The following APRN roles are listed with common organizations that accredit MSN programs in these respective APRN roles:
- Nurse Practitioner and Clinical Nurse Specialist – the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) accredit graduate programs for nurse practitioners and clinical nurse specialists (including psychiatric clinical nurse specialist)
- Nurse Anesthetist – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) accredits nurse anesthetist programs
- Nurse-Midwife – the Accreditation Commission for Midwifery Education (ACME) accredits nurse-midwife programs
Massachusetts Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses
For more specific details about the curriculum for APRN roles, candidates can look to the following nationally recognized professional organizations:
Nurse Practitioners – The National Task Force of Quality Nurse Practitioner Education describes the following requirements for a nurse practitioner graduate curriculum:
- The curriculum must be updated by current nurse practitioner faculty members
- It must meet standards for national certification in a population-focused area of practice
- It must include nurse practitioner role/population core competency objectives
- It must prepare prospective nurse practitioners to sit for a national certification exam that corresponds with the NP’s role and population focus
- The didactic and clinical curriculum plan must be consistent with nationally-recognized population-focused core skills
- Didactic coursework must be reinforced by clinical coursework
- The clinical segment must include at least 500 hours of supervised direct patient care
Clinical Nurse Specialist – The National Association of Clinical Nurse Specialists (NACNS) describes clinical nurse specialist academic requirements as follows:
- The CNS graduate program’s curriculum must be clearly aligned to address the care of a specific population, and be consistent with state requirements and nationally-recognized competencies
- Students should have RN licenses throughout their studies
- The curriculum must be accredited by a nursing education organization that is recognized by the US Department of Education
- Clinical courses must give students ample possibilities to develop skills in key areas that meet the CSN licensure or certification requirements
- The clinical segment must include at least 500 supervised hours
- The ideal clinical student-faculty ratio is recommended to be 1:1 or 2:1
Nurse-Midwife – The Accreditation Commission for Midwifery Education (ACME) specifies that the nurse-midwifery graduate curriculum must cover:
- Essentials of nurse midwifery, including the promotion of family-centered care
- Professional responsibilities of nurse midwives and the components of midwifery care
- Midwifery management process
- Perimenopausal, postmenopausal and care for other aging periods
- Management of common health problems
- Fundamentals of midwifery care
- Primary health care of women
- Gynecologic care
- Midwifery and health care for the childbearing woman and family
- Newborn care
During the clinical segment the nurse-midwife curriculum must cover all of these core competencies. Clinicals typically consist of at least 500 hours of supervised practice.
Nurse Anesthetist – The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires the CRNA graduate curriculum to include the following didactic elements:
- Ultrasound and radiology
- Advanced physiology and pathophysiology
- Advanced healthcare assessment
- Advanced pharmacology
- At least 135 hours covering pathophysiology, anatomy, and physiology
- At least 105 hours covering concepts in chemistry and biochemistry, pharmacology of anesthetic agents and adjuvant drugs
- At least 105 hours covering physics, pain management, equipment, technology, and basic-to-advanced principles of anesthesia practice
- At least 45 hours covering clinical correlation conferences
- At least 45 hours covering the professional aspects of the practice of nurse anesthesia
- At least 30 hours covering nurse anesthesia research
- The program must be at least 24 months in length, or its part-time equivalent
- Student applicants must be registered nurses with at least one year of experience in a critical-care setting
For the clinical segment, the COA also requires that students complete 2,000 hours of supervised clinical training and study at least 600 clinical cases.
Selecting the Right Program Based on Current Education
MSN programs may accept Massachusetts RNs from a range of educational backgrounds:
- RNs with a Bachelor’s of Science in Nursing (BSN) – These students can apply directly to conventional terminal MSN programs, which take about two years to complete
- RNs with an Associate’s degree in nursing (ADN) – These students can apply to RN-to-MSN bridge programs that offer fast-track completion options in as little as three years
- RNs with a Bachelor’s degree in an area other than nursing – These students can apply to entry-level or direct-entry MSN programs which allow for enrollment contingent upon completion of prerequisites; these programs can take around three years to complete
Scope of Practice and Maryland State Laws Governing Advanced Practice Registered Nursing
Laws pertaining to APRN nurses in Massachusetts can be found in the Code of Massachusetts Regulations (CMR) Title 244 Section 4. Professional Credential Services (PCS) also provides a compilation of relevant laws.
The Massachusetts Board of Registration in Nursing defines the general APRN scope of practice as follows:
- Advanced assessment, diagnosis, treatment, referrals, and consultations for individuals, groups or communities across the life span
- Treatment and care for health promotion or health maintenance, and for those who are experiencing acute or chronic disease, illness, or trauma
- Only those activities that are within the APRN’s authorized role, clinical category, and scope of practice competencies
- Only those activities that are within the accepted standards of APRN practice
In Massachusetts, APRNs may work independently without a supervising physician, provided they do not have prescriptive authority. The exception to this are certified nurse midwives, who may work and prescribe medications independent of a physician.
The board defines the following specific APRN scopes of practice as follows:
Certified Nurse Practitioner Scope of Practice:
- May only practice in the clinical category or categories for which the CNP has earned and maintained national certification
- Health promotion and disease prevention
- Health education, counseling, and referrals
- Diagnosis and management of acute and chronic illnesses/diseases
- Provide care in locations that include the home, hospitals, nursing facilities, private offices, public health clinics, and other ambulatory care settings
- May sign, certify, stamp, endorse, affidavit, or verify a law or rule in lieu of a physician where a law requires such, as long as it is within the CNP’s standards of practice
- May provide medical marijuana authorization
Clinical Nurse Specialist Scope of Practice:
- May only practice in the clinical category or categories for which the CNS has earned and maintained national certification
- Provide assistance to other nurses and health professionals
- Health promotion and disease prevention
- Health education, counseling, and referrals
- Diagnosis and management of acute and chronic illnesses/diseases
- Provide care in locations that include the home, hospitals, nursing facilities, private offices, public health clinics, and other ambulatory care settings
Psychiatric Clinical Nurse Specialist Scope of Practice:
- May only practice in the clinical category or categories for which the PCNS has earned and maintained national certification
- Health promotion and disease prevention
- Health education, counseling, and referrals
- Diagnose and manage acute chronic psychiatric illnesses/diseases
- Provide care in locations that include the home, hospitals, nursing facilities, private offices, public health clinics, and other ambulatory care settings
Certified Nurse Midwife Scope of Practice:
- May only practice in the clinical category or categories for which the nurse-midwife has earned and maintained national certification
- Practices within the standards determined by the American College of Nurse-Midwives (ACNM)
- Gynecological care
- Family planning services
- Preconception care, prenatal care, and postpartum care
- Childbirth care
- Care of a newborn
- Treatment of clients and partners for sexually transmitted diseases and reproductive health
- Interpretation of laboratory and diagnostic data within ACNM standards
- Develop clinical relationships with OB/GYNs, however a supervision agreement is not required
Certified Registered Nurse Anesthetist Scope of Practice:
- May only practice in the clinical category or categories for which the CRNA has earned and maintained national certification
- Provide care in diverse settings including hospitals, acute care centers, ambulatory centers, delivery rooms, dental offices, and physician/podiatrist offices
- Lacking prescriptive authority, a CRNA may administer anesthesia pursuant to a signed order of a registered prescriber
Prescriptive Authority for APRNs in Massachusetts
The Massachusetts Board of Registration in Nursing defines prescriptive practice as issuing written or oral prescriptions for controlled substances. The following APRN roles are eligible for prescriptive authority in Massachusetts:
- Certified nurse-midwife
- Certified nurse practitioner
- Psychiatric clinical nurse specialist
- Certified registered nurse anesthetist
Clinical nurse specialists may not prescribe medications.
To be eligible for prescriptive authority APRNs must take the following steps:
- Become authorized to practice as an APRN
- Register with the Department of Public Health’s Drug Control Program
- Register with the Drug Enforcement Administration (DEA)
- Except for nurse-midwives who may prescribe independently, CNPs, PCNSs, and CRNAs must establish prescriptive guidelines with a supervising physician
The prescriptive guidelines with a supervising physician must include:
- Name and credentials of supervising physician (who must work in the same area of practice as the APRN)
- Parameters of prescriptive practice
- Identification of any limitations placed on the prescriptive authority
- Instructions and procedures the APRN must follow when prescribing
- Instances that merit referral to, or consultation with, a physician
- Guidelines that address the ordering of tests and therapeutics, when appropriate
- Specify that the prescription of Schedule II drugs must be reviewed within 96 hours
APRNs must remember the following:
- They may prescribe hydrocodone-only extended release medications only within certain parameters such as:
- Other pain management options have been deemed inadequate, and a patient’s propensity to abuse medications has been assessed
- A letter of medical necessity has been supplied by the APRN
- The APRN enters into a pain management treatment agreement with the patient
APRNs may not prescribe Schedule II, III, and IV medications for themselves, and may only prescribe medications to family members under emergency circumstances.
APRNs must complete continuing education covering the following topics each time they renew their license, however there is no specific hour requirement for this:
- Effective pain management
- Identification of patients at high risk for substance abuse
- Patient counseling regarding the side effects and addictive nature of medications
- Patient counseling regarding the proper storage and disposal of medications
Implementation of the APRN Consensus Model in Massachusetts
The Massachusetts Board of Registration in Nursing shares the goals of the APRN consensus model developed by the National Council of State Boards of Nursing (NCSBN):
- Improve the quality of healthcare for patients
- Improve the access to healthcare for patients
- Improve APRN mobility throughout the United States
Today, after measurable progress, APRNs in Massachusetts can practice independently (non-prescriptively) without a supervising physician. However the NCSBN is still calling on the Massachusetts board to grant its APRNs greater prescriptive autonomy.
One of the most recent developments towards the fulfillment of the APRN consensus model came in August of 2014, when the following legislative changes were implemented:
- The current APRN roles and titles were defined
- The non-psychiatric role Clinical Nurse Specialist (CNS) was created
- It was clarified that APRNs could practice (non-prescriptively) without the supervision of a physician
- Certified nurse midwives became able to prescribe independently