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On June 30th, 2014, Hawaii Governor Neil Abercrombie signed a bill into law that grants advanced practice registered nurses (APRNs) signatory authority for provider orders for life-sustaining treatment (POLST), allowing them to honor a patient’s wishes as it pertains to invasive interventions during end of life care. The bill’s signing is just another step towards Hawaii’s increasing reliance on APRNs as primary healthcare providers.
To prepare for a career as an APRN in Hawaii, RNs must earn a Master of Science in Nursing (MSN) and achieve certification from a national body recognized by the Hawaii Board of Nursing. Through both classroom and clinical coursework, specialized MSN programs prepare RNs for a career in one of four APRN roles recognized in Hawaii:
- Nurse practitioner (NP)
- Certified registered nurse anesthetist (CRNA)
- Certified nurse-midwife (CNM)
- Clinical nurse specialist (CNS)
Master’s programs and national certification for nurse practitioners and clinical nurse specialists are further specialized according to one of six population foci: (Adult-Gerontology, Family/Individual Across the Lifespan, Neonatal, Pediatrics, Psychiatric/Mental Health, Women’s Health). National certifying bodies may offer additional specializations within population focus areas. Examples of these areas of specialty may include:
- Primary care
- Older adults
- Nephrology
- Critical care
According to the Hawaii Department of Commerce and Consumer Affairs, Professional & Vocational Licensing, there were 1,202 licensed APRNs in the state as of October, 2015. This figure marks a significant increase from the 910 active APRN licenses in 2010 and the 691 active APRN licenses in 2005. 2015 statistics published by the Department show the number of APRNs in each of the Hawaiian Islands:
- Oahu, 711
- Mainland, 277
- Hawai’i, 102
- Maui, 61
- Kauai, 42
- Molokai, 4
- Lanai, 2
While many of Hawaii’s MSN graduates go on to a career in advanced practice nursing, others elect to pursue nonclinical roles. Nursing directors, healthcare recruiters, and patient advocates are just some of the MSN-prepared nurses working in Hawaii’s 14 hospitals and dozens of physician’s offices.
Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses in Hawaii
The Hawaii Board of Nursing requires faculty members of the state’s MSN programs to be recognized as APRNs and hold a minimum of a master’s degree in nursing. Faculty members must also have at least one year of clinical nursing experience in their area of teaching responsibility.
By taking courses online, RNs are able to further their education without sacrificing current work obligations. For clinical sequences, students work with program advisors for placement at local medical facilities.
Hawaii’s MSN programs must adhere to the standards maintained by accrediting agencies and national certifying bodies specific to the four APRN roles:
- Nurse Practitioner and Clinical Nurse Specialist MSN programs are accredited by the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN)
- Nurse Anesthetist MSN programs are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA)
- Nurse-Midwife MSN programs are accredited by the American College of Nurse-Midwives (ACNM)
Accredited programs in the four roles include an established set of coursework designed to support the core competencies of the respective roles:
Certified Nurse Midwife (CNM) Program Requirements – The American College of Nurse Midwives (ACNM) requires all CNM programs to prepare graduate students for the core competencies for basic midwifery practice:
- Hallmarks of Midwifery
- Components of Midwifery Care: Professional Responsibilities of CNMs
- Components of Midwifery Care of Women
- Components of Midwifery Care of the Newborn
- Components of Midwifery Care: Midwifery Management Process
- Components of Midwifery Care: Fundamentals
Programs must offer courses in the following areas to prepare CNMs for the fundamental components of midwifery care:
- Nutrition
- Anatomy and physiology, including pathophysiology
- Psychosocial, sexual, and behavioral development
- Principles of individual and group health education
- Clinical genetics and genomics
- Normal growth and development
- Pharmacokinetics and pharmacotherapeutics
- Basic epidemiology
- Bioethics related to the care of women, newborns, and families
The ACNM also defines the clinical experience requirements for all CNM programs as follows:
- Management of sexually transmitted infections in male partners
- Management of primary care for women throughout the lifespan, including reproductive health care, pregnancy and birth
- Care of the normal newborn
- An AMCB-certified CNM or APRN who has clinical expertise and didactic knowledge commensurate with the content taught must supervise the clinical practice
- Attainment of clinical skills must meet Core Competencies for Basic Midwifery Education
Clinical Nurse Specialists (CNS) Program Requirements – The National Association of Clinical Nurse Specialists, the premier advocacy association for CNSs, requires all master’s CNS programs to meet criteria in these five areas:
- CNS Program Evaluation
- Student Admission, Progression and Graduation
- CNS Program Resources: Faculty, Clinical, and Institutional
- Program Organization and Administration
- CNS Curriculum
CNS programs must also prepare RNs in the following core competencies:
- Direct Care Competency
- Consultation Competency
- Systems Leadership Competency
- Collaboration Competency
- Coaching Competency
- Research Competency
- Ethical Decision-Making, Moral Agency and Advocacy Competency
Each competency has its own set of behavioral statements, found in detail on the Association website.
Certified Registered Nurse Anesthetist (CRNA) Program Requirements – The standards for master’s programs in nurse anesthesia are governed by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA). Programs must include coursework in the following areas:
- Clinical correlation conferences
- Preanesthetic preparation and evaluation
- Anesthesia practice
- Postanesthesia care
- Professional aspects of nurse anesthesia practice
- Research
- Pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry
- Perianesthetic and clinical support functions
- Basic and advanced principles of anesthesia practice including physics, equipment, technology and pain management
- Anesthesia induction, maintenance and emergence
- Anatomy, physiology, and pathophysiology
Programs must additionally offer students with clinical experience opportunities that allow for the following:
- Application of knowledge to clinical problems
- Testing of theory
- Learning of anesthesia techniques
Nurse Practitioner Program Requirements – The National Task Force on Quality Nurse Practitioner Education sets the standards for NP programs. Programs must offer courses that prepare students for the nine core competencies of professional practice:
- Scientific Foundation Competencies
- Quality Competencies
- Leadership Competencies
- Health Delivery System Competencies
- Technology and Information Literacy Competencies
- Ethics Competencies
- Independent Practice Competencies
- Policy Competencies
- Practice Inquiry Competencies
Programs must also prepare students for the NP Core Competencies based on population focus.
NP programs are also required to offer clinical experience opportunities that include a minimum of 500 supervised direct patient care clinical hours overall.
Selecting the Right Program Based on Current Education
Aspiring APRNs in Hawaii may pursue an MSN program structured to accommodate their current level of education:
Bachelor of Science in Nursing – Bachelor of Science in Nursing (BSN)-prepared nurses are eligible to apply to conventional MSN programs. These terminal BSN-MSN programs typically consist of between 40-60 course credits, which are earned over the course of 18-30 months.
Associate’s Degree in Nursing – RN-to-MSN programs give RNs that hold associate’s degrees the opportunity to complete both a BSN and MSN curriculum through just one accelerated program. These programs typically consist of seven-to-nine semesters of study that takes place over the course of two to three years, although part-time study may extend the completion process.
Bachelor’s Degree in an Area Other than Nursing – Direct-entry MSN programs are designed for professionals who have received a bachelor’s degree in an area other than nursing. Through an accelerated learning process, these programs help bachelor’s-educated professionals from non-nursing backgrounds earn their master’s degree in as little as 15-24 months.
Scope of Practice and State Laws Governing Advanced Practice Registered Nursing
The Hawaii Board of Nursing defines the scope of practice for APRNs in the state. While the scope of practice varies for APRNs based on role, patient population focus and specialty, all nurse practitioners, clinical nurse specialists, nurse-midwives and nurse-anesthetists may perform acts including, but not limited to:
- Provide direct care through assessment, planning, and implementation to patients by utilizing advanced scientific knowledge, skills, nursing and related theories
- Provide indirect care through planning, guiding, evaluating, and directing nursing care by other personnel on the health care team.
- Plan care, teach, or counsel group or individual patients
- Consult on areas of advanced clinical knowledge and skills to those involved directly or indirectly in patient care
- Take part in joint and periodic evaluation of services rendered
- Develop various networks as appropriate with other health care professionals.
- Manage patient’s prescribed plan of care
- Record initiation and maintenance; authorization of appropriate regulatory and other legal documents
- Establish and implement community educational programs about health care
- Research population trends related to health care and determining at-risk groups
- Analyze health care policies related to specialty practice and collaborate with other professionals to develop new policies
- Collaborate with other health care professionals on issues related to health care delivery systems
The Hawaii Board of Nursing defines the scope of practice for specific APRN roles as follows:
Certified Nurse Midwife (CNM)
Under the board’s scope of practice, Hawaii CNMs may perform acts including, but not limited to:
- Independently manage women’s health care with a focus on the following areas:
- Pregnancy
- Childbirth
- Newborn care
- The postpartum period
- The gynecological needs of women
- Perform acts that meet the standards of practice set forth by the American College of Nurse-Midwives (ACNM), unless noted otherwise by the Board.
Clinical Nurse Specialist (CNS)
Depending on area of specialty, a CNS may perform acts including, but not limited to:
- Evaluate the health status of patients in physical, developmental, and psychosocial areas through approved practice methods
- Manage health care for selected client populations
- Initiate and maintain various documents related to health care
The following types of CNSs are recognized in Hawaii:
- Gerontological CNS
- Medical-Surgical CNS
- Community Health CNS
- Adult Psychiatric & Mental Health CNS
- Child & Adolescent Psychiatric & Adult Mental Health CNS
- Maternal-Child CNS
- Pain-Management CNS
- Community Mental Health CNS
- Critical Care CNS
- Adult CNS
- Family/Child CNS
- Parent-Child CNS
- Pediatric CNS
- Oncology CNS
- Advanced Diabetes Management CNS
Certified Registered Nurse Anesthetist (CRNA)
CRNAs have the authority to perform acts including, but not limited to:
- Perform and document total anesthesia care of patients
- Create and oversee anesthetic care plans
- Support life functions during the perioperative period
- Oversee aspects of patient medication during the perioperative period
- Respond to unexpected patient responses during anesthesia through approved methods
- Discharge patients from a post-anesthesia care area
- Participate in the life support of patients
- Implement management modalities for acute and chronic pain
Nurse Practitioner (NP)
Depending on area of specialty, an NP may perform acts including, but not limited to:
- Evaluate the physical and psychosocial health status of patients through various methods
- Assist in surgery
- Order, interpret, or perform various tests and procedures approved by the board
- Formulate a diagnosis
- Plan, implement, and evaluate care
- Perform approved acts related to rehabilitation therapies, medical nutritional therapy, social services and psychological and other medical services
- Monitor therapeutic interventions’ effectiveness
- Admit and discharge clients for inpatient care at the following licensed facilities:
- Hospitals
- Long-term care facilities
- Hospice
The following types of NPs are recognized in Hawaii:
- Adult NP
- Gerontological NP
- Pediatric NP
- Acute Care NP
- Neonatal NP
- School NP
- Women’ s Health Care NP
- Psychiatric Mental Health NP
- Family NP
- Family Health NP
- Community Mental Health NP
- Ambulatory Care NP
- Advanced Diabetes Management NP
- Advanced Oncology Certified NP
Continuing Education Requirements for APRNs in Hawaii
APRNs in Hawaii who have not applied for prescriptive authority are exempt from the state’s Continuing Education (CE) requirements for RNs.
However, all APRNs must renew their license with the Hawaii Board of Nursing on June 30 of every odd-numbered year and provide proof of their current national certification in their role and patient population focus. APRNs would consult with their certifying body for information on certification maintenance.
The Hawaii Board of Nursing recognizes the following national certification agencies in each APRN role and patient population focus:
Nurse Practitioners
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)
- Family Nurse Practitioner-Board Certified (FNP-BC)
- Gerontological Nurse Practitioner-Board Certified (GNP-BC)
- Pediatric Primary Care Nurse Practitioner-Board Certified (PPCNP-BC)
- Adult-Gerontology Acute Care Nurse Practitioner-Board Certified (AGACNP-BC)
- Adult-Gerontology Primary Care Nurse Practitioner-Board Certified (AGPCNP-BC)
- Psychiatric-Mental Health Nurse Practitioner-Board Certified (PMHNP-BC)
- Adult Psychiatric-Mental Health Nurse Practitioner-Board Certified (PMHNP-BC)
- School Nurse Practitioner-Board Certified (SNP-BC)
AACN Certification Corporation
- Acute Care Nurse Practitioner Adult-Gerontology (ACNPC-AG)
- Acute Care Nurse Practitioner Adult (ACNPC) – not aligned with APRN Consensus Model
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)
Certified Nurse-Midwives
American Midwifery Certification Board
- Certified in Nurse-Midwifery (CNM)
Clinical Nurse Specialists
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)
- Acute/Critical Care Clinical Nurse Specialist (Adult, Pediatric & Neonatal) (CCNS) – not aligned with APRN Consensus Model
American Nurses Credentialing Center
- Adult Health Clinical Nurse Specialist-Board Certified (ACNS-BC)
- Adult-Gerontology Clinical Nurse Specialist-Board Certified (AGCNS-BC)
- Adult Psychiatric-Mental Health Clinical Nurse Specialist-Board Certified (PMHCNS-BC)
- Child/Adolescent Psychiatric-Mental Health Clinical Nurse Specialist-Board Certified (PMHCNS-BC)
- Gerontological Clinical Nurse Specialist-Board Certified (GCNS-BC)
- Home Health Clinical Nurse Specialist-Board Certified (HHCNS-BC)
- Pediatric Clinical Nurse Specialist-Board Certified (PCNS-BC)
- Public/Community Health Clinical Nurse Specialist-Board Certified (PHCNS-BC)
Certified Registered Nurse Anesthetist (CRNA)
National Board of Certification and Recertification for Nurse Anesthetists
- Certified Registered Nurse Anesthetist (CRNA)
APRN Consensus Model, Independent Practice and Prescriptive Authority in Hawaii
Hawaii is one of eleven U.S states to have adopted all major components of the national APRN consensus model, a set of rules established by over 40 nursing organizations to provide uniformity in the regulation of APRN roles in each state. Hawaii’s APRNs may practice independently with full prescriptive authority and do not require a collaborative practice agreement with a physician as described in the Hawaii Administrative Rules for Nurses.
APRNs in Hawaii may earn prescriptive authority provided they submit the following to the Hawaii Board of Nursing:
- Application for prescriptive authority
- Proof of a current, unencumbered RN license
- Proof of a current, unencumbered recognition or license as an APRN
- Proof of successful completion of at least thirty contact hours in advanced pharmacology education including advanced pharmacotherapeutics as part of the curriculum of the nurse’s master’s degree program (hours must be completed within the three-year time period immediately preceding the date of application).
An APRN who has earned prescriptive authority earns the distinction of an APRN-Rx and may prescribe and administer over-the-counter and legend drugs, controlled substances within their specialty, as well as any drugs not found on the state’s Exclusionary Formulary. According to the formulary, APRNs may not prescribe the following substances:
- Investigational drugs except as part of an IRB-approved clinical trial
- Stimulants and hormones for treatment of obesity
- Human Growth hormones, anabolic steroids, or hormones for performance enhancement or decreasing the impact of aging
- Methadone for maintenance or detoxification of a narcotic-dependent person
- Medical marijuana