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The state of Montana is home to 103 separate areas classified as health professional shortage areas (HPSAs) and another 55 locales that have been recognized as medically under-served areas according to the US Health and Human Services Administration. These figures underline a critical need in the state for qualified healthcare professionals to serve as primary care providers and specialists, and advanced practice registered nurses (APRNs) are seen as the solution.
A Master of Science in Nursing (MSN) in advanced clinical practice remains the standard for APRNs in their various roles, while MSN specialty tracks are also available in clinical leadership, nursing education, administration and more. In all cases, an MSN offers the assurance of greater autonomy, respect, and better pay. Data published by the US Department of Labor in 2014 shows the clear distinction between salaries for two advanced practice roles as compared to salaries for ADN and BSN-educated RNs:
- Nurse anesthetists – average annual salary $115,110
- Nurse practitioners – average annual salary $92,800
- Registered nurse – average annual salary $61,810
As of 2015, active APRN licenses in Montana in the four Board-recognized roles were distributed as follows:
- Certified nurse practitioner – 838 throughout Montana
- Certified registered nurse anesthetist – 173 throughout Montana
- Certified nurse midwife – 67 throughout Montana
- Clinical nurse specialist – 38 throughout Montana
Licensing Requirements for the APRN Roles Recognized by the Montana Board of Nursing
The Montana Board of Nursing licenses APRNs in four distinct roles:
- Certified Nurse Practitioner (CNP)
- Certified Registered Nurse Anesthetist (CRNA)
- Certified Nurse Midwife (CNM)
- Clinical Nurse Specialist (CNS)
To be eligible for APRN licensure through the Montana Board of Nursing, candidates must meet these requirements:
- Have a current Montana RN license, or simultaneously submit an application for such
- Complete a graduate-level degree program with a focus on one or more of the four APRN roles
- Gain national certification from a board-recognized organization
- Pass a criminal background check
Nurse practitioners and clinical nurse specialists focus their graduate education and earn national certification in a specific population focus, such as family-individual across the lifespan; adult-gerontology primary or acute care; neonatal; women’s health; psychiatric-mental health. Nurse midwives and nurse anesthetists do not specialize in a particular population group.
Montana participates in the National Council of State Boards of Nursing (NCSBN) Nurse Licensure Compact, which allows practice mobility among the 25 participating states.
The Montana Board of Nursing recognizes the following national certifying organizations as granting the certification necessary for APRN licensure in the four respective roles:
- Nurse-Midwives – American Midwifery Certification Board (AMCB)
- Nurse Anesthetists – National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA)
- Nurse Practitioners and Clinical Nurse Specialists – these national organizations certify NPs and CNSs in their primary role and patient population focus:
Earning an Master of Science in Nursing (MSN) in Montana
An MSN is the basic education requirement for APRNs in Montana. Local options for MSN programs can be found in Bozeman.
Students can also pursue their MSN online, which offers the added advantage of a self-paced format and part time options that allows working RNs to maintain their professional obligations while completing a graduate program. Accelerated options are also available for full time students. Graduate schools offering MSN programs online maintain partnerships with local schools and hospitals in Montana to maximize convenience for a student’s clinical education segment. In many cases, clinical sequences can be completed with the student’s current employer.
As a condition for state licensure and national certification, APRN candidates must graduate from accredited programs recognized by the respective certification agencies:
- Nurse Practitioner and Clinical Nurse Specialist Program Accreditation – the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) are two predominant accrediting agencies for nurse practitioner and clinical nurse specialist programs, however other accrediting agencies recognized by the Council for Higher Education Accreditation (CHEA) and the US Department of Education may also be accepted
- Nurse Anesthetist Program Accreditation – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is the accrediting agency recognized by the NBCRNA
- Nurse-Midwife Program Accreditation – the Accreditation Commission for Midwifery Education (ACME) is the accrediting agency recognized by the AMCB
Montana Requirements for MSN Programs that Prepare Advanced Practice Registered Nurses
While all graduate programs for advanced practice registered nurses include advanced training in health assessment, pathophysiology, and pharmacology, professional nursing organizations can help prospective APRNs in each of the four roles understand what their specific curriculum will cover:
Clinical Nurse Specialist Program Curriculum – The National Association of Clinical Nurse Specialists (NACNS) describes the clinical nurse specialist curriculum as follows:
- It must be accredited by a nursing education organization that is recognized by the US Department of Education
- The curriculum must be clearly aligned to address the care of a specific population, and in line with nationally-recognized competencies and state requirements
- It must be led by a CNS who has at least a master’s degree in the program’s population focus
- Clinical courses must give students plenty of opportunities to develop skills in key areas and meet the CNS licensure requirements
- The clinical student-faculty ratio should be high
- Master’s-level clinical course preparation must include at least 500 supervised clinical hours
Nurse Practitioners Program Curriculum – The National Task Force of Quality Nurse Practitioner Education describes the nurse practitioner curriculum as follows:
- It must meet the standards for national certification in a population-focused area of practice and be continuously updated by current nurse practitioner faculty members
- The curriculum must prepare the prospective nurse practitioner 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 competencies
- NP population focus core competency objectives must be included in the curriculum
- Didactic coursework must be reinforced by clinical coursework
- The clinical segment must include at least 500 hours of supervised direct patient care
Nurse Anesthetist Program Curriculum – The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires the CRNA graduate curriculum to include the following didactic elements:
- Advanced physiology and pathophysiology
- Advanced healthcare assessment
- Advanced pharmacology
- Ultrasound and radiology
- 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 must also complete 2,000 hours of supervised clinical training and study at least 600 clinical cases.
Nurse-Midwife Program Curriculum – The Accreditation Commission for Midwifery Education (ACME) describes the nurse-midwifery graduate curriculum as follows:
- Promotion of family-centered care and the hallmarks of midwifery
- Components of midwifery care
- Primary health care of women
- Professional responsibilities of nurse midwives
- Midwifery management process
- Newborn care
- Fundamentals of midwifery care
- Gynecologic care, perimenopausal, postmenopausal and care for other aging periods
- Management of common health problems
- Childbearing family
Typically the clinical segment of a nurse-midwife graduate program will include at least 500 supervised hours of direct patient care.
Selecting the Right Type of MSN Program Based on Current Education
MSN programs may consider admitting nurses and non-nursing professionals from all types of educational backgrounds:
- Nurses with a Bachelor of Science in Nursing (BSN) – RNs with a BSN can apply directly to conventional MSN programs and earn their degree in about two years
- Nurses with an Associate Degree in Nursing (ADN) – RNs with an ADN can apply to RN-to-MSN bridge programs that often result in a BSN along the way; these programs can take around three years to complete
- Professionals with a bachelor’s degree in an area other than nursing – Professionals with an unrelated bachelor’s degree can apply to entry-level/direct-entry MSN programs that allows them to complete the requirements for an MSN and RN license in around three years
Scope of Practice and Montana State Laws Governing Advanced Practice Registered Nursing
APRNs can become licensed and practice within the laws and scope of practice described in the Administrative Rules of Montana (ARM), Chapter 24.159 Board of Nursing, especially Subchapter 14.
In general, the Montana Board of Nursing describes the APRN scope of practice as follows:
- APRNs are accountable to patients, the nursing profession, and to the board
- APRNs must comply with the rules and statutes for the quality of advanced nursing care rendered
- APRNS must recognize the limits of their knowledge and experience when it comes to planning and management of situations beyond their expertise
The Board describes the specific scope of practice for the four APRN roles as follows:
Scope of Practice for Certified Nurse Practitioners
- Practice in independently and collaboratively to manage the primary and acute-care needs of individuals, families, and communities
- Practice in a variety of healthcare settings
- Practice within the nurse practitioner’s population focus
- Population foci can be adult/geriatric, pediatric, neonatal, family/individual health across the lifespan, women’s/gender-related, and psychiatric/mental health
Scope of Practice for Nurse Midwives
- Practice in independently and collaboratively to manage the care of women throughout their lifespan
- Apply knowledge as a nurse midwife who is certified in the population focus of women’s/gender-related health
- Provide a full range of primary healthcare services to women throughout the lifespan
- Provide services that include family planning services, gynecological care, preconception care, prenatal care, postpartum care, childbirth, and care of the newborn
- Provide services in a variety of healthcare settings
Scope of Practice for Nurse Anesthetists
- Practice independently and collaboratively to manage acts related to anesthesia services
- Acts may be related to the determination, preparation, administration, or monitoring of anesthesia care and the management of chronic or acute pain
- Provide services as a nurse anesthetist who is certified in the population focus of family/individual health across the lifespan
- Health levels of patients can include all levels of acuity, such as immediate, severe, and life-threatening
Scope of Practice for Clinical Nurse Specialists
- Practice in independently and collaboratively to manage and deliver individuals, families, groups, and communities
- Integrate nursing practices which focus on assisting patients, preventing, or resolving illness, disease, injuries, and disabilities
- Provide direct patient care
- Influence care outcomes by providing expert consultation for nursing staff
- Implement improvements in healthcare delivery systems
- Population foci may include adult/geriatric, neonatal, pediatric, psychiatric/mental health, and family/individual
Prescriptive Authority for APRNs in Montana
APRNs can apply for prescriptive authority if they have completed three semester graduate credits relating to advanced pharmacology. This must include the study of pharmacodynamics, pharmacokinetics, and pharmacotherapeutics.
If the APRN plans to prescribe Schedule drugs, such as Schedule II-V drugs, they must register with the Drug Enforcement Administration (DEA).
APRNs may not prescribe drugs for themselves or their immediate family members. All prescriptions written by an APRN must adhere to state and federal guidelines.
Prescriptive authority must be renewed concurrently with the APRN license every two years. To be eligible for this, APRNs must complete 12 hours of continuing education in pharmacotherapeutics, with not more than two of these hours covering the topics of herbal or complementary therapies. These 12 hours can count towards the 24 hours of continuing education required to renew an APRN license.
Independent Practice for APRNs and the Implementation of the APRN Consensus Model in Montana
Compared with many other states, APRNs in Montana have a high level of autonomy:
- They can work as independent healthcare providers
- They can prescribe medication independently after gaining prescriptive authority
- They are not required to work under the supervision of a physician
The National Council of State Boards of Nursing (NCSBN) is leading a nation-wide effort to enact the APRN Consensus Model with the goal of increasing access to healthcare and allowing APRNs greater mobility throughout the country. Since legislation that took effect in September 2013, most of the NCSBN’s goals for its APRN Consensus Model have been implemented in Montana:
- Separate licensing procedure for an APRN license (independent of an RN license)
- Four defined APRN roles with their own distinct scopes of practice
- APRN independent practice and prescriptive authority
Continuing Education Requirements for APRNs in Montana
APRN licenses must be renewed concurrently with RN licenses by December 31st of even-numbered years. To be eligible to renew the APRN license, candidates must maintain their traditional RN license and complete the following:
- Maintain national certification
- Complete 24 hours of continuing education within the two years prior to renewing – acceptable continuing education is approved by an accrediting organization, and provided by a college or university, a continuing education provider, or an APRN national certifying organization
- Maintain a quality assurance plan
The quality assurance plan is an individualized document that details specific actions an APRN is taking to maintain and improve their professional proficiency. It provides details about:
- The APRNs role, experience, practice setting, and population focus
- Peer reviews, institutional reviews, and self-assessments
- How the APRN plans to maintain and improve competence in providing patient care and evaluating outcomes
- How the APRN is meeting the professional standards developed by the national certifying organization