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A look at the 2016 US Department of Health and Human Services (HHS) map of Health Professional Shortage Areas (HPSAs) in South Dakota makes one thing starkly apparent: virtually every area outside of the state’s five largest cities has been identified as having a shortage of primary-care providers, earning them a spot on the list of the state’s HPSAs. In fact, HHS has identified 86 areas in South Dakota that fit into this classification. As the problem continues to become more acute, increasing the number of actively licensed advanced practice nurses (APNs) skilled in advanced health assessment, pathophysiology and pharmacology is widely recognized as the solution.
The demand for healthcare professionals is so great in the state’s rural areas that in 2015 the South Dakota State University College of Nursing was among the first in the nation to receive a grant from the US Department of Health and Human Services in the amount of $1.25 million to develop a telehealth curriculum designed to train nurse practitioners, nurse-midwives, and clinical nurse specialists to provide healthcare services online to patients in rural areas.
As the minimum education requirement for RNs entering advanced clinical practice, as well as for those entering nonclinical roles in administration, nursing education, informatics, case management and more, a Master of Science in Nursing (MSN) is the starting point for careers that involve a greater level of responsibility and higher pay.
Licensing Requirements for the APN Roles Recognized in South Dakota
The South Dakota Board of Nursing licenses advanced practice nurses (APNs) in four different roles: (shown here with the total number of active licenses for each as of 2014):
- Certified nurse practitioners – 651 actively licensed; up 48 percent from 2010 levels
- Clinical nurse specialists – 71 actively licensed; remaining fairly constant from 2010 levels
- Certified nurse midwives – 32 actively licensed; up 36 percent from 2010 levels
- Certified registered nurse anesthetists – 440 actively licensed; up 15 percent from 2010 levels
By statute, South Dakota allows its APNs to refer to themselves as advanced practice registered nurses (APRNs) in alignment with the APRN Consensus Model, though the Board still officially uses “APN.”
To be eligible for licensure in any of these roles, candidates must fulfill these requirements:
- Pass a criminal background check
- Have a current RN license issued in South Dakota or in a nurse licensure compact state
- Complete a master’s program at minimum with a concentration in one of the four APN roles
- Become certified in the APN role (and patient population focus, as applicable) by a board-approved national certification organization
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).
Applicants for APN licensure can apply for a temporary permit if they have met all requirements except national certification.
The national certification organizations approved by the South Dakota Board of Nursing to grant credentials for the purpose of APN licensure in the state are shown here:
- Nurse Practitioners:
- Clinical Nurse Specialists:
- Nurse-Midwives:
- Nurse Anesthetists:
Earning an Master of Science in Nursing (MSN) in South Dakota
Completing an MSN degree program is the underlying educational requirement for any APN role in South Dakota. Approved MSN programs are located in the cities of:
- Sioux Falls (two programs)
- Rapid City
- Brookings
Students can also consider accredited online MSN programs offered by colleges and universities throughout the nation. By considering online programs, students open up a greater range of APN role and population focus concentration options. Program coordinators strive to develop relationships with other universities and hospitals throughout the Dakotas to allow their students to complete clinical segments locally. In many cases, graduate nursing students can complete clinical sequences with their current employer.
National certification organizations and the South Dakota Board of Nursing only consider applicants who graduate from properly accredited programs:
- Nurse Practitioner and Clinical Nurse Specialist – the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) are the two most prominent accrediting agencies recognized by national certification organizations for nurse practitioner and clinical nurse specialist programs
- Nurse Anesthetist – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is the accrediting agency recognized by the NBCRNA
- Nurse-Midwife – the Accreditation Commission for Midwifery Education (ACME) is the accrediting agency recognized by the AMCB
Requirements for MSN Programs that Prepare Advanced Practice Nurses
The curriculum requirements for each APN role are specified by the following organizations:
Nurse Practitioners – the National Task Force of Quality Nurse Practitioner Education specifies that the nurse practitioner graduate curriculum must include:
- A didactic and clinical curriculum plan that is consistent with nationally-recognized population-focused competencies
- A curriculum that is continuously updated by current nurse practitioner faculty members
- The curriculum must meet the standards for national certification in a population-focused area of practice
- Core competency nurse practitioner objectives must be included in the curriculum
- The curriculum must prepare the prospective nurse practitioner to sit for a national certification exam that corresponds with the NP’s population focus
- 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 standards as follows:
- The curriculum must be clearly aligned to address the care of a specific population, and be congruent with state requirements and nationally-recognized competencies
- The program must be led by a CNS who has at least a master’s degree in the particular area of focus of the CNS program
- The curriculum must be accredited by a nursing education organization that is recognized by the US Department of Education
- There must be an adequate number of faculty instructors and preceptors to ensure there is direct and indirect supervision of students during clinical courses
- Clinical courses must give students ample opportunities to develop skills in key areas to meet the licensure requirements
- The clinical segment must include at least 500 supervised hours
Nurse-Midwife – the Accreditation Commission for Midwifery Education (ACME) specifies that a nurse-midwifery graduate program curriculum must include:
- Hallmarks of midwifery, including the promotion of family-centered care
- Professional responsibilities of nurse midwives and the components of midwifery care
- Midwifery management process
- Fundamentals of midwifery care
- Primary health care of women
- Gynecologic care, perimenopausal, postmenopausal and care for other aging periods
- Management of common health problems
- Childbearing family
- Newborn care
Typically, the clinical segment of an MSN program for nurse-midwives includes at least 500 hours of supervised experience.
Nurse Anesthetist – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires the CRNA graduate program curriculum to include the following didactic elements:
- Ultrasound and radiology
- Advanced pharmacology
- Advanced health care assessment
- Advanced physiology and pathophysiology
- 30 hours covering nurse anesthesia research
- 45 hours covering professional aspects of the practice of nurse anesthesia
- 45 hours covering clinical correlation conferences
- 105 hours covering physics, pain management, equipment, technology, and basic-to-advanced principles of anesthesia practice
- 105 hours covering concepts in chemistry and biochemistry, pharmacology of anesthetic agents and adjuvant drugs
- 135 hours covering pathophysiology, anatomy, and physiology
Students also must complete 2,000 hours of supervised clinical training and study at least 600 clinical cases.
Selecting the Right Program Based on Current Education
RNs can choose from MSN programs that are designed to cater to their current level of education, whether an associate’s or bachelor’s degree:
- RNs with a Bachelor’s of Science in Nursing (BSN) – these candidates can apply directly to MSN programs, which take about two years to complete
- RNs with an Associate’s degree in nursing (ADN) – these candidates can apply to RN-to-MSN bridge programs which offer completion options in as little as three years
- RNs with a Bachelor’s degree in an area other than nursing – these candidates can apply to entry-level or direct-entry MSN programs which allow for enrollment that is contingent upon completion of prerequisites; these programs can take around three years to complete
State Laws Concerning Advanced Practice Nursing in South Dakota
South Dakota laws pertaining to APNs can be found through the following sources:
- South Dakota Statutes, Chapter 36-9A – for nurse practitioners and nurse midwives
- South Dakota Statutes, Chapter 36-9 – for clinical nurse specialists and nurse anesthetists
These statutes define the specific APN scopes of practice, which supplement the general RN scope of practice.
APN Collaborative Agreements in South Dakota
In South Dakota, the different APN roles have different requirements for physician collaboration:
Nurse Practitioner and Nurse Midwife Collaborative Agreement – These advanced clinicians must work within a collaborative agreement with a supervising physician who practices in the same area as the nurse practitioner or nurse midwife (APN). This agreement details the specific scope of practice for the APN.
Collaboration for nurse practitioners and nurse-midwives is defined as follows:
- It can be made by direct personal contact, and may be supplemented by telecommunications
- It must include at least two direct, personal meetings per month
- When not in direct contact, the physician must be available via telecommunications
- The collaborating physician must be on-site every 90 days at a practice location where regular health care services are performed
Substitute collaborating physicians may be named in the event that the primary supervising physician becomes temporarily unavailable.
If nurse practitioners or nurse midwives are opting for prescriptive authority, the collaborative agreement must also include details about what medications may be prescribed, and how the APN will assess patient outcome.
Nurse Anesthetist Physician Collaboration – These advanced clinicians may only perform anesthetic services in the office of a physician or at a licensed health care agency. When performing these services, they must do so in collaboration with a physician. In this case, collaboration means communicating pertinent information to a collaborating physician or health care team.
Clinical Nurse Specialist Physician Supervision – These advanced clinicians must work under the general supervision of a physician.
Prescriptive Authority for APNs in South Dakota
South Dakota’s nurse practitioners and nurse midwives can be granted prescriptive authority by taking the required steps. Clinical nurse specialists and nurse anesthetists, however, cannot prescribe or distribute medications under any circumstances.
Nurse practitioners and nurse midwives can gain prescriptive authority if it is specified in their collaborative agreement, and if they have completed advanced coursework in pharmacotherapeutics.
If they want to prescribe controlled substances, they must apply for a controlled substance registration with the South Dakota Department of Health. The department will confirm that controlled substance prescription is authorized in the nurse practitioner or nurse midwife’s collaborative agreement. Next the nurse practitioner or nurse midwife must register with the Drug Enforcement Administration (DEA).
Implementation of the APN Consensus Model in South Dakota
The APRN Consensus Model developed by the National Council of State Boards of Nursing (NCSBN) and supported by a consortium of more than 40 nursing organizations sets a standardized definition for APRN roles and seeks to achieve a common national standard for education and certification. South Dakota has adopted many of the NCSBN’s recommendations, which are aimed at achieving the goals of improving access to, and the quality of, health care:
- The South Dakota Board of Nursing recognizes the title, “APRN”
- The licensing process to become an APN is unique for each role, and separate from the licensing process to become an RN
- A supplementary scope of practice is defined for each APN role
One of the major courses of action the South Dakota Board of Nursing has yet to take to implement the APRN Consensus Model fully is to grant all APNs in the state the authority to practice and prescribe independently, without the requirement for a collaborating physician.
However, due to the legislative influence of physician groups, full practice and prescriptive independence is not a short-term goal of organizations like the Nurse Practitioner Association of South Dakota (NPASD). The NPASD can be thought of as speaking for all APN professionals as it lists the following items as priorities for legislative advocacy for 2016:
- Ensure full and cost-effective health care for all persons
- Promote a full scope of practice for nurse practitioners – and by extension each APN role
- Promote education and learning for professionals
Continuing Education Requirements for APNs in South Dakota
All APNs must renew their APN license every two years. To be eligible for renewal they must maintain their national certification and keep their RN license in good standing.