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Common among faculty nurse educators, nurse administrators, nurse informaticists and advanced clinicians, including clinical nurse leaders, nurse practitioners, certified nurse midwives and clinical nurse specialists, is the Master of Science in Nursing (MSN). With specialty tracks in each of these nonclinical and advanced clinical roles, earning an MSN is an inevitable step for registered nurses interested in specialty practice and career advancement.
In 2016, the US Department of Health and Human Services identified 26 primary care health professional shortage areas located throughout New Hampshire. Though this is an alarming figure, it also shows the growing number of opportunities available to the state’s advanced practice registered nurses (APRNs), who enjoy full autonomy and the ability to practice and prescribe without physician oversight, allowing them to serve as independent primary care providers.
This increasing demand for primary care providers and specialists is reflected in job growth projections for New Hampshire’s APRNs in a number of roles (as published by the New Hampshire Economic and Labor Market Information Bureau in 2012 for the ten-year period spanning 2012 to 2022):
- Nurse practitioners – projected job growth rate of 31%
- Nurse midwives – projected job growth rate of 30%
- Nurse anesthetists – projected job growth rate of 21%
The value of New Hampshire’s advanced practice registered nurses is also reflected in the salaries they earn. While the state’s ADN and BSN-prepared RNs earned an average of $65,790 in 2014, graduate-prepared APRNs consistently earned six-figure salaries. In fact, New Hampshire’s nurse anesthetists earned the highest average salary in the nation, while the state’s nurse-midwives earned the fifth highest (US Department of Labor 2014):
- Nurse practitioners – average salary $100,000
- Nurse midwives – average salary $111,700
- Nurse anesthetists – average salary $222,060
Licensing Requirements for the APRN Roles Recognized by the New Hampshire Board of Nursing
To become licensed as an APRN through the New Hampshire Board of Nursing, candidates must fulfill these conditions:
- Have an unencumbered RN license in New Hampshire or another compact state
- Earn at least an MSN – this must include:
- At least 225 hours of content that relates to theoretical nursing
- At least 480 hours of clinical nursing practice
- A course on pharmacological interventions
- Submit proof of national certification by a board-recognized organization – this can be submitted up to 120 days after the application for APRN licensure, pending which, a temporary license may be issued
- Pass a criminal background check
The New Hampshire Board of Nursing identifies these four APRN roles as being the most common and lists them on its application for licensure (nurses from nurse licensure compact states and out-of-state applicants for licensure by endorsement will recognize these as different from the APRN roles identified in most other states):
- Adult Nurse Practitioner
- Pediatric Nurse Practitioner
- Certified Registered Nurse Anesthetist
- Nurse Midwife
Still, the Board will recognize nurse practitioners that have focused their education and become nationally certified in patient populations other than adult and pediatric. These other patient population foci would include: family-individual across the lifespan, adult-gerontology primary or acute care, neonatal, women’s health, or psychiatric-mental health.
The New Hampshire Board of Nursing may also grant APRN licensure via endorsement for nurses from non-compact states provided they have completed equivalent requirements to become APRNs in their home state.
National Certification Organizations
The New Hampshire Board of Nursing recognizes these national certification organizations as being authorized to confer the credentials necessary for APRN licensure in the Board-recognized roles and patient population foci:
- Nurse-Midwives – American Midwifery Certification Board (AMCB)
- Nurse Anesthetists – National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA)
- Nurse Practitioners:
Earning an Master of Science in Nursing (MSN) in New Hampshire
Working RNs often prefer to complete accredited graduate programs online. The flexibility that online programs offer is often the deciding factor for RNs interested in pursuing a master’s degree, but who need to maintain a normal work schedule. Some MSN programs allow for additional flexibility with part-time and accelerated options. Schools that offer online programs make every effort to develop ties with medical facilities around the country so as to offer students the convenience of being able to complete clinical sequences at a location close to home. In many cases, RNs are able to complete clinical requirements at their current place of employment.
Fulltime students that prefer a campus-based experience will find MSN programs available at local schools throughout New Hampshire in the cities of Portsmouth, Nashua, Durham and Manchester.
The following organizations are responsible for accrediting online and campus-based graduate nursing programs that offer specialty tracks in the different APRN roles:
- Nurse Practitioner and Clinical Nurse Specialist programs are accredited by these prominent accrediting bodies: The Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN)
- Nurse Anesthetist programs are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA)
- Nurse-Midwife programs are accredited by the Accreditation Commission for Midwifery Education (ACME) is the accrediting body recognized by the AMCB
MSN Requirements for Programs that Prepare Advanced Practice Registered Nurses
Prospective MSN students can get an idea of what to expect in their curriculum by examining the standards set by nationally recognized organizations:
Nurse Practitioners (Adult, Pediatric, and additional population sub-foci) – the National Task Force of Quality Nurse Practitioner Education describes the nurse practitioner graduate curriculum as follows:
- The curriculum must meet the standards for national certification in a population-focused area of practice
- Nurse practitioner core competency 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
- The curriculum must be continuously updated by current nurse practitioner faculty members
- The didactic and clinical curriculum plan must be consistent with nationally-recognized population-focused competencies
- Didactic coursework must be reinforced by clinical coursework
- At least 500 hours of supervised direct patient care clinical hours must be included
Nurse-Midwife – the Accreditation Commission for Midwifery Education (ACME) specifies that the nurse-midwife graduate program curriculum must cover:
- Midwifery management process
- Childbearing family
- Newborn care
- Fundamentals of midwifery care
- Primary health care of women
- Hallmarks of midwifery, including the promotion of family-centered care
- Professional responsibilities of nurse midwives and the components of midwifery care
- Gynecologic care, perimenopausal, postmenopausal and care for other aging periods
- Management of common health problems
Nurse Anesthetist – the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) requires the nurse anesthetist graduate program curriculum to include these didactic elements:
- Ultrasound and radiology
- Advanced pharmacology
- Advanced healthcare assessment
- Advanced physiology and pathophysiology
- Pathophysiology, anatomy, and physiology – total 135 hours
- Physics, pain management, equipment, technology, and basic-to-advanced principles of anesthesia practice – 105 hours total
- Concepts in chemistry and biochemistry, pharmacology of anesthetic agents and adjuvant drugs – total 105 hours
- Professional aspects of the practice of nurse anesthesia – 45 hours
- Clinical correlation conferences – 45 hours
- Nurse anesthesia research – 30 hours
The curriculum must also include 2,000 hours of supervised clinical training and coverage of at least 600 clinical cases.
Selecting the Right Program Based on Current Education
Aspiring nurse graduate students will find MSN programs are structured in a number of different ways to accommodate RNs with different degrees:
- RNs with a Bachelor of Science in Nursing (BSN) – Those with a BSN can apply directly to standard terminal MSN programs, which take approximately two years to complete
- RNs with an Associate Degree in Nursing (ADN) – Those with an ADN can apply to RN-to-MSN bridge programs, which result in both a BSN and MSN in one accelerated program that usually takes three years to complete
- Professionals with a Bachelor’s degree in an area other than nursing – Individuals with a bachelor’s degree in an unrelated field can apply to direct-entry/entry-level MSN programs that result in a BSN, RN license and MSN from one accelerated program that takes around three years to complete
Scope of Practice and New Hampshire State Laws Governing Advanced Practice Registered Nursing
The regulations pertaining to APRNs in New Hampshire can be found in the following documents:
APRN Scope of Practice in New Hampshire
The New Hampshire Board of Nursing’s position statement on the APRN scope of practice has been designed to mirror the main tenets of the National Council of State Boards of Nursing’s (NCSBN) APRN Consensus Model. It defines the scope of practice for its APRNs (adult and pediatric nurse practitioners, nurse midwives, and nurse anesthetists) as follows:
- Treating and assessing patients using a combination of knowledge and skills acquired from education
- Performance of advanced assessment
- Diagnosing, prescribing, and administration of treatment regimens
- Transference and referral of patients as appropriate
- Providing functions that are common for APRNs in the area for which they are prepared educationally and experientially
- Possess, prescribe, administer, and dispense controlled substances and non-controlled drugs
- Provide functions that are common to the APRN as determined by their national certification organization
- Practice within the standards of an established national credentialing or certification body
These last two points allow this somewhat general scope of practice to be expanded to the specific APRN roles traditionally recognized by national certification and accrediting organizations:
Prescriptive Authority for APRNs in New Hampshire
The New Hampshire APRN license comes with the authority to prescribe, administer, and dispense medications. Controlled substance prescriptive authority requires some additional steps:
- Register with the New Hampshire Prescription Drug Monitoring Program
- Drug Enforcement Administration (DEA)
When writing prescriptions for controlled substances that are intended for pain control, APRNs must abide by these guidelines:
- Document each prescription
- Work within appropriate treatment standards for chronic pain
- Comply with all state and federal laws pertaining to controlled substances
- Adhere to national professional guidelines
The state has adopted further regulations that pertain to the prescription of opioids:
- When prescribing for acute pain, APRNs must inform their patients about the specific risks and means of use for opioids
- When prescribing for chronic pain, APRNs must inform their patients about the disposal of unused medications and:
- Obtain an informed consent
- Conduct a patient risk assessment
- Establish a written pain agreement
- Conduct toxicology screenings as necessary
Because New Hampshire is largely rural, APRNs are also permitted to prescribe medications to family members and themselves in emergency situations or in isolated settings when other qualified healthcare providers are unavailable.
Independent Practice and the Implementation of the APRN Consensus Model in New Hampshire
New Hampshire respects the autonomy of APRNs, allows the full independent practice of APRNs as primary healthcare providers, and grants them full prescriptive authority. A 2014 article in the online publication Science-Based Medicine cited New Hampshire as the quintessential example of a state that recognizes its APRNs as licensed and regulated independent practitioners.
In a rural state like New Hampshire where APRNs may be practicing in isolated settings, the ability to practice independently without physician oversight is particularly important and pertinent.
Senate Bill 66, implemented in July 2009, brought several changes to the state’s APRN rules and regulations regarding the National Council of State Boards of Nursing’s (NCSBN) APRN Consensus Model. The Model aims to improve APRN mobility throughout the nation and thereby increase access to quality healthcare.
The New Hampshire Board of Nursing has adopted rules that have helped the state further align with the APRN Consensus Model:
- Reclassification of advanced RNs as APRNs, with a licensing procedure that is separate from that of RNs
- Granting full independent practice authority to APRNs, which includes full prescriptive authority
While New Hampshire is ahead of many states, it could also take further steps to implement the APRN consensus model by doing the following:
- Define the four APRN roles as nurse practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist
- Define a specific scope of practice for each of these roles
Continuing Education Requirements for APRNs in New Hampshire
APRN licenses must be renewed at the same time as the traditional RN license: every two years by midnight of the APRN’s birthday. To be eligible for renewal, candidates must meet these conditions during each renewal cycle:
- Maintain a current and valid RN license
- Have provided at least 400 hours of APRN nursing care
- Have completed 30 hours of continuing education to maintain the traditional RN license, and an additional 30 hours of continuing education to maintain the APRN license
- Maintain national certification (up to 30 hours of continuing education completed for certification maintenance can count towards state requirements for APRN license renewal)
The 30 hours of continuing education to maintain the APRN license must include:
- At least 5 hours that pertain to pharmacology as it is related to the APRN’s role and population focus
- At least 20 hours that pertain to the APRN’s specific role and population focus