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Consensus Model for Advanced Practice Registered Nurse Regulation

Consensus Model for Advanced Practice Registered Nurse Regulation

In 2004, an APRN Consensus Conference was convened to achieve consensus regarding the credentialing of APRNs (APRN Joint Dialogue Group, 2008; Stanley et al., 2009) and the development of a regulatory model for advanced practice nursing. Independently, the APRN Advisory Committee for the National Council of State Boards of Nursing (NCSBN) was charged by the NCSBN Board of Directors with a similar task of creating a future model for APRN regulation and, in 2006, disseminated a draft of the APRN Vision Paper (NCSBN, 2006), a document that generated debate and controversy. Within a year, these groups came together to form the APRN Joint Dialogue Group, with representation from numerous stakeholder groups, and the outcome was the APRN Consensus Model (APRN Joint Dialogue Group, 2008).

The APRN Consensus Model includes important definitions of roles, titles, and population foci. Furthermore, it defines specialties and describes how to make room for the emergence of new APRN roles and population foci within the regulatory framework. A timeline for adoption and strategies for implementation were put forth, and progress has been made in these areas (see Chapter 20 for further information; only the model is discussed here).

APRN Consensus Model Overview

AspectDetails
Year Established2008
Primary FocusCredentialing and regulation of APRNs
Key ComponentsDefinitions of roles, titles, population foci, specialties
Four APRN RolesNurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), Certified Nurse-Midwife (CNM)
Six Population FociFamily/Individual across the lifespan, Adult/Gerontology, Neonatal, Pediatrics, Women’s Health/Gender-related, Psychiatric/Mental Health
Licensure RequirementsBased on educational preparation and population focus
Certification RequirementsMust align with area of study
Regulatory ProcessesLicensure, Accreditation, Certification, Education (LACE)

For further details, refer to the National Council of State Boards of Nursing.

The definition of the components of the APRN Consensus Model begins to address some of the questions about advanced practice posed earlier in this chapter. An important agreement was that providing direct care to individuals is a defining characteristic of all APRN roles. This agreement affirms a position long held by original and current editors of this text—that when there is no direct practice component in the role, one is not practicing as an APRN. It also has important implications for LACE and for career development of APRNs.

Graduate education for the four APRN roles is described in the Consensus Model document (APRN Joint Dialogue Group, 2008). It must include completion of at least three separate, comprehensive graduate courses in advanced physiology and pathophysiology, physical health assessment, and advanced pharmacology (the “three Ps”), consistent with requirements for the accreditation of APRN education programs. In addition, curricula must address three other areas—the principles of decision making for the particular APRN role, preparation in the core competencies identified for the role, and role preparation in one of the six population foci.

The Consensus Model asserts that licensure must be based on educational preparation for one of the four existing APRN roles and a population focus, that certification must be within the same area of study, and that the four separate processes of LACE are necessary for the adequate regulation of APRNs (APRN Joint Dialogue Group, 2008; see Chapter 20). The six population foci displayed in Fig. 2.1 include the individual and family across the lifespan as well as adult/gerontologic, neonatal, pediatric, women’s health/gender-specific, and psychiatric/mental health populations. Preparation in a specialty, such as oncology or critical care, cannot be the basis for licensure. Specialization indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty area could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations).

Important Points of the Consensus Model

AspectDetails
Direct Care ProvisionMandatory for all APRN roles
Core CompetenciesMust be developed by each APRN role
Educational RequirementsAdvanced physiology and pathophysiology, health assessment, pharmacology
Specialty CertificationNot a basis for licensure; additional knowledge in discrete areas
Regulatory ProcessesMust include licensure, accreditation, certification, education (LACE)

This was a critical decision for the group to reach, given the numbers of specialties and APRN specialty examinations in place when the document was prepared.

Even with this brief overview of the APRN Consensus Model, one sees how this model advanced the conceptualization of advanced practice nursing. It is helpful for many reasons. First, for the United States, it affirms that there are four APRN roles. Second, it is advancing a uniform approach to LACE and advanced practice nursing that has practical and policymaking effects, including better alignment between and among APRN curricula and certification examinations. Furthermore, it addresses the issue of differentiating between RNs and APRNs and has been foundational to differentiate among nursing roles. By addressing the issue of specialization, the model offers a reasoned approach for the following: (1) avoiding confusion from a proliferation of specialty certification examinations; (2) ensuring that, because of a limited and parsimonious focus (four roles and six populations), there will be sufficient numbers of APRNs for the relevant examinations to ensure psychometrically valid data on test results; and (3) allowing for the development of new APRN roles or foci to meet society’s needs.

FAQs About the APRN Consensus Model

Q: What are the four recognized APRN roles? A: The four recognized APRN roles are Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), and Certified Nurse-Midwife (CNM).

Q: What are the six population foci in the APRN Consensus Model? A: The six population foci are Family/Individual across the lifespan, Adult/Gerontology, Neonatal, Pediatrics, Women’s Health/Gender-related, and Psychiatric/Mental Health.

Q: Why is direct care provision mandatory for all APRN roles? A: Providing direct care is a defining characteristic of all APRN roles, ensuring that the practice is aligned with advanced practice nursing standards.

Q: What are the “three Ps” in APRN education? A: The “three Ps” are advanced physiology and pathophysiology, physical health assessment, and advanced pharmacology.

Q: Can specialization be the basis for APRN licensure? A: No, specialization indicates additional knowledge and expertise in a more discrete area of practice, but it cannot be the basis for licensure.

Although there are a number of noted strengths of the Consensus Model, there are also limitations. First, competencies that are common across APRN roles are not addressed beyond defining an APRN and indicating that students must be prepared “with the core competencies for one of the four APRN roles across at least one of the six population foci” (APRN Joint Dialogue Group, 2008, p. 10). The model leaves it to the different APRN roles to develop their own core competencies.

In addressing specialization, the model also leaves open the issue of the importance of educational preparation, in addition to experience, for advanced practice in a specialty, which is of particular importance to the CNS role. Additionally, Martsolf and colleagues (2020) recently raised concerns regarding the misalignment between specialty NP education, certification, and practice location and called for an evaluation of the policy and practice implications of the Consensus Model, along with an examination of the scope and scale of NP misalignment within healthcare systems.

Two years after the 2004 APRN consensus conference, the American Association of Colleges of Nursing (AACN, 2006) put forth “The Essentials of Doctoral Education for Advanced Nursing Practice.” The Essentials established the DNP, the highest practice degree and the preferred preparation for specialty nursing practice. The AACN called for doctorate-level preparation of APRNs by the year 2015. DNP preparation for entry to practice has been endorsed by the Council on Accreditation of Nurse Anesthesia Educational Programs (2019), the National Association of Clinical Nurse Specialists (NACNS, 2015), and the National Organization of Nurse Practitioner Faculties (NONPF, 2015). However, the American College of Nurse-Midwives (ACNM, 2019) has not endorsed the DNP as a requirement for entry into practice for

CONCEPTUALIZATIONS OF ADVANCED PRACTICE NURSING ROLES: ORGANIZATIONAL PERSPECTIVES

CONCEPTUALIZATIONS OF ADVANCED PRACTICE NURSING ROLES: ORGANIZATIONAL PERSPECTIVES

Advanced Practice Nursing: Transforming Healthcare Today

Practice with individual clients or patients is the central work of the field; it is the reason for which nursing was created. The following questions are the kinds of questions a conceptual model of advanced practice nursing should answer:

Scope and Purpose of Advanced Practice Nursing

Advanced Practice Nursing (APN) encompasses a wide range of responsibilities and roles aimed at providing high-quality healthcare. The primary scope of APN includes diagnosing and treating illnesses, prescribing medications, and managing patient care. APNs work in various settings, including hospitals, clinics, and private practices.

InformationDetails
Scope of PracticeDiagnosing and treating illnesses, prescribing medications, managing patient care
SettingsHospitals, clinics, private practices
Role DifferencesExpanded scope compared to traditional nurses, similar to physicians in many respects
Required Knowledge and SkillsAdvanced clinical training, strong diagnostic skills, ability to prescribe medications
Patient OutcomesImproved patient satisfaction, better health outcomes, cost-effective care
Healthcare SystemsEmploy APNs to address shortages, improve quality of care, reduce costs
Patient BenefitsEnhanced care for complex conditions, better management of chronic diseases
Addressing DiversityFocus on social determinants of health, culturally competent care
Model RevisionsContinuous updates to reflect evolving healthcare needs

For more detailed information, refer to ANCC.

Characteristics of Advanced Practice Nursing

Advanced Practice Nurses (APNs) are characterized by their advanced clinical training and expertise in specific areas of healthcare. They hold master’s or doctoral degrees and are certified in their specialties. APNs include Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Nurse Anesthetists (CRNAs), and Nurse Midwives (CNMs).

  1. Education and Certification: APNs must complete rigorous educational programs and obtain certification in their specialty areas.
  2. Clinical Expertise: They possess in-depth knowledge and clinical skills that enable them to provide comprehensive care.
  3. Patient-Centered Care: APNs focus on holistic and patient-centered care, addressing the physical, emotional, and social needs of patients.

Settings for Advanced Practice Nursing

APNs practice in diverse settings, each offering unique opportunities and challenges:

  • Hospitals: Inpatient care, emergency departments, specialized units.
  • Clinics: Outpatient care, community health centers, specialty clinics.
  • Private Practices: Independent or collaborative practices with other healthcare providers.
  • Educational Institutions: Faculty positions, clinical educators.

Differences in Scope of Practice

APNs differ from other healthcare providers in several ways:

  • Broader Scope: APNs have a wider scope of practice compared to traditional nurses, often similar to that of physicians.
  • Autonomy: They can practice independently in many states, while others require collaborative agreements with physicians.
  • Prescriptive Authority: APNs have the authority to prescribe medications, including controlled substances, in most states.

Knowledge and Skills Required

APNs require a diverse set of knowledge and skills:

  • Advanced Clinical Training: Specialized education in diagnosing and managing complex health conditions.
  • Diagnostic Skills: Ability to conduct comprehensive assessments and develop treatment plans.
  • Prescriptive Authority: Knowledge of pharmacology and the ability to prescribe medications safely.
  • Leadership and Collaboration: Skills in leading healthcare teams and collaborating with other providers.

Outcomes of APN Care

The outcomes of care delivered by APNs are significant and well-documented:

  • Patient Satisfaction: Higher levels of patient satisfaction due to personalized and holistic care.
  • Health Outcomes: Improved management of chronic conditions and better overall health outcomes.
  • Cost-Effectiveness: Reduction in healthcare costs due to preventive care and effective management of diseases.

Employing APNs in Healthcare Systems

Healthcare systems benefit from employing APNs in various ways:

  • Addressing Shortages: APNs help fill gaps in healthcare provider shortages, especially in underserved areas.
  • Improving Quality of Care: APNs contribute to higher quality of care through their expertise and patient-centered approach.
  • Reducing Costs: APNs provide cost-effective care by focusing on prevention and efficient management of chronic diseases.

Addressing Pressing Healthcare Problems

APNs are integral in solving many pressing healthcare issues:

  • Chronic Disease Management: Providing comprehensive care for patients with chronic conditions.
  • Preventive Care: Focusing on prevention and early intervention to reduce the burden of diseases.
  • Health Disparities: Addressing social determinants of health and providing culturally competent care to diverse populations.

Conceptual Models in Advanced Practice Nursing

Conceptual models in APN are essential for guiding practice and education:

  • Holistic Models: Emphasizing the interrelationship between patients, health, and the environment.
  • Collaborative Practice: Models that focus on collaboration between APNs and other healthcare providers.
  • Role Differentiation: Clarifying the unique roles and contributions of APNs compared to other healthcare professionals.

By clearly defining the phenomenon and related concepts, these models ensure consistency and effectiveness in advanced practice nursing.

FAQs

What is the main focus of Advanced Practice Nursing? The main focus of APN is to provide comprehensive, high-quality healthcare, including diagnosis, treatment, and management of health conditions.

How do APNs differ from traditional nurses? APNs have advanced clinical training, broader scope of practice, and the authority to prescribe medications, unlike traditional nurses.

What are the benefits of employing APNs? Employing APNs leads to improved patient outcomes, higher patient satisfaction, and cost-effective care.

How do APNs address social determinants of health? APNs focus on providing culturally competent care and addressing the social and economic factors that affect health.

Conceptualizations of Advanced Nurse Practitioner: Problems and Imperatives

Conceptualizations of Advanced Nurse Practitioner: Problems and Imperatives

Introduction

Despite the usefulness and benefits of conceptual models, conceptual confusion and uncertainty remain regarding advanced nurse practitioner roles. One noted issue is the lack of a well-defined and consistently applied core stable vocabulary used for model building. Despite progress, this challenge remains.

Vocabulary Variations

Different Terms in Different Regions

  • In the United States, “advanced practice nursing” is the term used, but the ICN and CNA use “advanced nursing practice.”
  • Variations in definitions exist between Australia, Canada, New Zealand, the United States, Canada, and the United Kingdom.

Role Confusion

  • The term “advanced practitioner” is used to describe non-APRN experts in the United Kingdom and internationally.
  • Different states in the U.S. use various terms for APRNs:
    • Iowa: Advanced Registered Nurse Practitioner
    • Virginia: Licensed Nurse Practitioner

The APRN Consensus Model

The APRN Consensus Model (APRN Joint Dialogue Group, 2008) represents a major step forward in promulgating a uniform definition of advanced practice in the United States for the purpose of regulation. However, the lack of a core vocabulary continues to make comparisons difficult because the conceptual meanings vary.

Competencies and Concepts

  • Competencies are more commonly used to describe APRN practice concepts.
  • Reflection on and discussion of terms such as roles, hallmarks, functions, activities, skills, and abilities continue, contributing to the urgent need for a common language.

Addressing Nursing’s Metaparadigm

Few models of APRN practice comprehensively address nursing’s metaparadigm (person, health, environment, nursing). Comparing, refining, or developing models is challenging because concepts are often used without universal meaning or consensus, and sometimes with inconsistent definitions.

Evolution and Clarity in APRN Practice

  • The evolution of advanced nurse practitioner roles will be enhanced if scholars and practitioners agree on fundamental concepts of APRN practice.
  • A clear differentiation of APRN practice from registered nurses (RNs) is necessary.

International and Global Models

Current Status

  • Few conceptual models describe the practice and outcomes of APRNs.
  • The United Arab Emirates is emerging in APRN roles but lacks a formal model.

Need for Diverse Models

  • Models addressing diverse health and cultural needs worldwide are required.

Distinguishing APRNs from Physicians

Role Clarity

  • Clarifying differences in practice between APRNs and physicians is crucial.
  • Lack of conceptual clarity in job advertisements can lead to confusion.

Barriers to Practice

  • Organized medicine attempts to limit or discredit APRNs.
  • Lack of conceptual clarity can hinder APRNs from practicing to the full extent of their education and training.

Interprofessional Education and Practice

Interprofessional education and practice are central to high-quality care. Graduate education of APRNs alongside other health professionals is beginning to take place, enhancing collaborative care.

Example: University of Michigan

  • An interprofessional clinical decision-making course includes students from nursing (APRN students), pharmacy, dentistry, medicine, and social work.

Development of Interprofessional Competencies

  • High-functioning interprofessional teams are critical for maximizing patient outcomes.
  • Conceptual models for APRN practice on interprofessional teams are needed.

Imperatives for Conceptual Consensus

Among many imperatives for reaching a conceptual consensus on advanced nurse practitioner roles, the interrelated areas of policymaking, licensing, credentialing, and practice are most important.

Policymaking

  • Not all APRNs are eligible for reimbursement by insurers.
  • The APRN Consensus Model and other reforms call for changes to enable APRNs to work within their full scope of practice.

Continued Dialogue

  • Ongoing dialogue and activity are essential for clarifying advanced nurse practitioner roles and concepts.

Box 2.1: Clarification and Consensus on Conceptualization of Advanced Nurse Practitioner Roles

  1. Clear differentiation of advanced nurse practitioner roles from other levels of clinical nursing practice.
  2. Clear differentiation between advanced nurse practitioner roles and the clinical practice of physicians and other non-nurse providers.
  3. Clear understanding of APRNs’ roles and contributions on interprofessional teams.
  4. Clear delineation of similarities and differences among APRN roles.
  5. Regulation and credentialing of APRNs that protect the public.
  6. Clear articulation of health policies that:
    1. Recognize APRNs’ contributions to quality, cost-effective healthcare.
    2. Ensure public access to APRN care.
    3. Ensure appropriate billing and payment mechanisms for APRN care.
  7. Maximizing social contributions by APRNs in healthcare.
  8. Enabling APRNs to reach their full potential personally and professionally.

By addressing these issues, the conceptualization of advanced nurse practitioner roles can be clarified, enhancing the understanding and practice of APRNs globally.

Conceptual Models in Advanced Nurse Practitioner Practice

Conceptual Models in Advanced Nurse Practitioner Practice

Nature, Purposes, and Components of Conceptual Models

A conceptual model is a critical part of the structure of nursing knowledge, encompassing various levels from abstract to concrete. This structure includes metaparadigms, philosophies, conceptual models, theories, and empirical indicators (Fawcett & Desanto-Madeya, 2013). Traditionally, key concepts in the metaparadigm of nursing are humans, the environment, health, and nursing (Fawcett & Desanto-Madeya, 2013).

What is a Conceptual Model?

Fawcett and Desanto-Madeya (2013) described a conceptual model as:

  • A set of relatively abstract and general concepts addressing the phenomena central to a discipline.
  • Propositions that broadly describe these concepts.
  • Propositions that state relatively abstract and general relations between two or more of the concepts.

Additionally, a conceptual model is a distinctive frame of reference that guides observation and interpretation of phenomena of interest to the discipline. It provides alternative ways to view the subject matter, without a single “best” way (Fawcett & Desanto-Madeya, 2013).

Importance in Advanced Nurse Practitioner Roles

Evolving a more uniform and explicit conceptual model for advanced practice nursing benefits patients, nurses, and other stakeholders by:

  1. Facilitating communication.
  2. Reducing conflict.
  3. Ensuring consistency in advanced practice nursing.

This systematic approach enhances nursing research, education, administration, and practice (Institute of Medicine, 2011).

Applications of Conceptual Models in Advanced Nurse Practitioner Practice

Professional Identity and Clinical Practice

Conceptual models help Advanced Nurse Practitioners (ANPs) articulate professional role identity and function. These models serve as frameworks for:

  • Organizing beliefs and knowledge about professional roles and competencies.
  • Further development of knowledge.

In clinical practice, ANPs use conceptual models for holistic, comprehensive, and collaborative care (Carron & Cumbie, 2011; Dunphy, Winland-Brown, Porter, Thomas & Gallagher, 2011; Elliott & Walden, 2015; Musker, 2011).

Differentiation in Nursing Practice

Conceptual models differentiate among levels of nursing practice, such as:

  • Staff nursing vs. advanced practice nursing (Gardner et al., 2013).
  • Clinical nurse specialists (CNSs), nurse-midwives (CNMs), and nurse practitioners (NPs; Begley et al., 2013).

Guiding Research and Theory Development

Conceptual models guide research and theory development by focusing on specific concepts or examining relationships among select concepts to elucidate testable theories. For example, Gullick and West (2016) evaluated Wenger’s community of practice framework to enhance research capacity and productivity for CNSs and NPs in Australia.

Educating Future Advanced Nurse Practitioners

Faculty use conceptual models to plan curricula for APRN roles, identifying key concepts and their relationships, and making choices about course content and clinical experiences (Perraud et al., 2006; Wong et al., 2010).

Conceptual Questions in Advanced Practice

Fawcett and Graham (2005) and Fawcett et al. (2004) have posed important questions about advanced practice:

  • What do ANPs do that makes their practice “advanced”?
  • To what extent does incorporating activities traditionally done by physicians qualify nursing practice as “advanced”?
  • Are there nursing activities that are also advanced?

Direct Clinical Practice and APRN Competencies

Direct clinical practice is central to ANP competency, raising questions about the meaning of “clinical” in various settings, such as hospitals or clinics. These questions are crucial given the APRN Consensus Model and the evolving role of ANPs in healthcare (Hamric, 2014).

Innovations and Reforms in Advanced Nurse Practitioner Practice

Healthcare legislation changes and regulations emphasize the need for ANPs to be explicitly engaged in delivering care across settings, including:

  • Nursing clinics.
  • Palliative care settings.
  • Interprofessional teams.

Theoretical Questions and Conceptualization

Theoretical questions about the conceptualization of advanced practice nursing include:

  • Epistemologic, philosophic, and ontologic underpinnings of advanced practice.
  • Application of nursing theory in practice.
  • Differences between specialty, advanced practice, and advancing practice.

Summary

Well-thought-out, robust conceptual models are essential for guiding ANP practice. Conceptual clarity benefits patients, the nursing profession, and interprofessional education and practice (CIHC, 2010; Health Professions Network Nursing and Midwifery Office, 2010; IPEC Expert Panel, 2016). It supports the creation of accountable care organizations and builds systems for effective communication, collaboration, and coordination, leading to high-quality care and improved outcomes.

Advanced Nurse Practitioner Education

Advanced Nurse Practitioner Education

Overview of Advanced Nurse Practitioner Growth

During the 1990s, the number of Advanced Nurse Practitioners (ANPs) increased dramatically in response to the growing demand, the national emphasis on primary care, and a decrease in medical residencies in subspecialties.

Expansion of ANP Programs

  1. 1990s Growth:

    • In 1990, there were 135 master’s degree programs and 40 certificate programs for ANPs.
    • Between 1992 and 1994, the number of institutions offering ANP education more than doubled from 78 to 158.
    • By 1994, institutions offered multiple tracks, leading to a total of 384 ANP tracks in master’s programs across the United States.
    • By 1998, the number of institutions offering ANP education doubled again, resulting in 769 distinct ANP specialty tracks.
  2. Master’s and Post-Master’s Programs:

    • Most programs were at the master’s or post-master’s level.
    • In 2013, there were 368 institutions offering a master’s degree in ANP.
    • Additionally, 92 colleges offered a postbaccalaureate Doctor of Nursing Practice (DNP) degree.

Recent Trends in ANP Education

Since 2015, there has been rapid growth in DNP programs for ANP education nationwide.

Key Developments

  • 2020 Data:
    • According to the DNP Directory, in 2020 there were 357 DNP programs.
    • There were more than 106 new programs in the planning stage.

Nationwide Trends

Clearly, the trend nationwide is toward the DNP as the requirement for ANP practice.

Evolution of Neonatal and Acute Care Advanced Nurse Practitioners

Evolution of Neonatal and Acute Care Advanced Nurse Practitioners

Emergence of Neonatal Advanced Nurse Practitioners

  • Historical Background

    • In the late 1970s, the neonatal Advanced Nurse Practitioner (ANP) role was developed to address a shortage of neonatologists.
    • Restrictions on pediatric residents’ time in neonatal intensive care units further highlighted the need for this role.
  • New Responsibilities

    • Highly skilled neonatal nurses took on tasks previously handled by pediatric residents.
    • Responsibilities included interhospital transport of critically ill infants and newborn resuscitation.

Growth of Adult Acute Care Advanced Nurse Practitioners

Responding to Healthcare Needs

  • Residency Shortages

    • Similar to the neonatal role, the adult acute care ANP role emerged due to shortages in intensive care unit residencies.
    • Policies limiting resident physicians to 80 hours per week further drove the need for acute care ANPs.
  • Complex Tertiary Care Systems

    • Increasingly complicated tertiary care systems lacked proper coordination.
    • Advanced Nurse Practitioners stepped in to ensure quality patient care and provide leadership in healthcare delivery.

Academic and Certification Milestones

  1. Early Academic Efforts

    • Professors Anne Keane and Therese Richmond documented the emergence of the Acute Care Nurse Practitioner (ACNP) role, initially termed “The Tertiary NP.”
    • This role focused on providing specialized care in a fragmented healthcare system.
  2. Program Proliferation and Consensus

    • Between 1992 and 1995, master’s programs with ACNP tracks expanded across the country.
    • Annual ACNP consensus conferences began in 1993 to address curriculum content.
  3. Certification and Integration

    • The ANA’s Credentialing Center administered the first ACNP certification examination in December 1995.
    • By 1997, 43 programs prepared ACNPs at the master’s or post-master’s level.
    • In 2002, ACNPs merged with the American Academy of Nurse Practitioners, uniting primary care NPs and ACNPs.

The Rise of Advanced Nurse Practitioners in the 21st Century

  • Increasing Appeal of the NP Role

    • Growth in NP programs, expanded prescriptive authority, and greater practice autonomy made the NP role attractive.
    • More nurses chose to become Advanced Nurse Practitioners.
  • Organizational Developments

    • Various organizations represented different NP specializations, including:
      • American Academy of Nurse Practitioners
      • National Association of Pediatric Nurse Associates and Practitioners (NAPNAP)
      • Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
    • Despite offering competing certification exams, these groups agreed on requiring master’s education for the NP role.
  • Unified Representation

    • In 2013, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners merged to form the American Association of Nurse Practitioners (AANP).

Conclusion

The evolution of the Advanced Nurse Practitioner roles, particularly in neonatal and acute care, reflects a dynamic response to healthcare needs. From addressing physician shortages to ensuring coordinated and specialized patient care, Advanced Nurse Practitioners have become integral to modern healthcare delivery.

Advanced Nurse Practitioner: Growth, Organization, and Legislation

Advanced Nurse Practitioner: Growth, Organization, and Legislation

Significant Growth in Advanced Nurse Practitioners

The latter part of the 20th century witnessed substantial growth in the number of Advanced Nurse Practitioners (ANPs) and their national organizations. The ANP role diversified significantly, giving rise to new specializations such as:

  • Emergency Nurse Practitioner
  • Neonatal Nurse Practitioner
  • Family Nurse Practitioner
  • Acute Care Nurse Practitioner

By 1984, approximately 20,000 graduates from ANP programs were employed in various settings envisioned by the founders (Kalisch & Kalisch, 1986, p. 715):

  • Outpatient clinics
  • Health maintenance organizations
  • Health departments
  • Community health centers
  • Rural clinics
  • Schools
  • Occupational health clinics
  • Private offices

Expansion to Tertiary Care Centers

By the late 1980s, ANPs, particularly those with specialty training, were increasingly employed in tertiary care centers, reflecting their success in neonatal intensive care units (Silver & McAtee, 1988).

Organizational Development and Legislative Influence

The multiple roles of ANPs created competing interests, impacting their ability to unify on legislative issues. Key organizational developments included:

  1. Primary Health Care Nurse Practitioner Council – Established by the ANA to address legislative challenges.
  2. American Academy of Nurse Practitioners – Formed in 1985 as the first organization for ANPs across all specializations.
  3. American College of Nurse Practitioners – Created in 1995 to serve as a “SWAT team” on policy during President Clinton’s healthcare reform initiative, aiming to unite all ANP organizations.

Legislative Milestones in the Early 1990s

Federal legislation in the early 1990s, particularly the Controlled Substances Act, significantly impacted ANP prescriptive authority:

  1. DEA’s Initial Proposal (1991) – Proposed registration for “affiliated practitioners” with prescriptive authority tied to a collaborating physician’s number. This was criticized and revoked in 1992.
  2. DEA’s Amended Regulations (1992) – Introduced the category of “mid-level providers” (MLPs), allowing ANPs to receive individual DEA numbers starting with an M, provided they had state-granted prescriptive authority.

Key Outcomes

  • The MLP provision, effective in 1993, greatly expanded ANPs’ ability to prescribe controlled substances (DEA, 1993).

Through these organizational and legislative advancements, Advanced Nurse Practitioners solidified their role and authority in the healthcare landscape, ensuring broader access to healthcare services and enhanced professional recognition.

Resistance to the Advanced Nurse Practitioner by Organized Medicine

Resistance to the Advanced Nurse Practitioner by Organized Medicine

Overview

Although physicians and Advanced Nurse Practitioners (ANPs) collaborated at the local level, organized medicine began to express its resistance to the ANP role. One of the most contentious areas of interprofessional conflict involved prescriptive authority for nursing.

Nurse Practitioners and Prescriptive Privileges

The fight for prescriptive authority for Advanced Nurse Practitioners (ANPs) spanned the latter decades of the 20th century.

Historical Context

  • 1983: Only Oregon and Washington granted ANPs statutory, independent prescriptive authority.
  • Other States: Required direct supervision by a licensed physician.

Prescription Handling

  • Physician Availability: Depended on the negotiated boundaries of the physician–ANP team and locality.
  • Remote Clinics: Physicians might countersign prescriptions weekly or pre-sign prescription pads for ANPs.
  • State Variations: Practices varied, with some states requiring physicians to write and sign prescriptions at the ANP’s request.

Legal and Regulatory Developments

  • 1971: Idaho recognized diagnosis and treatment as part of the specialty nurse’s scope of practice.
  • Drug Enforcement Act: Required practitioners to obtain DEA registration numbers to prescribe controlled substances.

Progress and Challenges

Throughout the 1980s, ANPs worked tirelessly to convince state legislatures to pass laws and establish reimbursement policies that would support their practice. Interprofessional conflicts with organized medicine and, to a lesser extent, with pharmacists, centered on control issues and the degree of independence the ANP was allowed. These conflicts intensified as ANPs moved towards a more autonomous model.

Seminal Legal Case

Sermchief v. Gonzales (1983)

  • Initial Ruling: Missouri medical board charged two women’s healthcare ANPs with practicing medicine without a license.
  • Appeal: Missouri Supreme Court overturned the decision, allowing the scope of ANP practice to evolve without statutory constraints.

Policy and Perception

In 1986, a government report concluded that ANPs and Certified Nurse-Midwives provided care equivalent in quality to that provided by physicians. However, the American Medical Association House of Delegates opposed empowering nonphysicians to become unsupervised primary care providers.

Access to Cost-Effective, Quality Health Care for All Americans

Key Findings

  • 1986 Government Report: Concluded that ANPs provided care equivalent in quality to physicians within their areas of competence.

Opposition

  • American Medical Association: Passed a resolution to oppose any attempt at empowering nonphysicians to become unsupervised primary care providers and be directly reimbursed.

Summary

The evolution of prescriptive authority and practice autonomy for Advanced Nurse Practitioners has been marked by significant legislative and legal challenges. Despite resistance from organized medicine, ANPs have achieved recognition and expanded roles, contributing to accessible and high-quality healthcare.

The Concept of Advanced Nurse Practitioner

The Concept of Advanced Nurse Practitioner

Defining Advanced Nurse Practitioner in the 1980s

During the 1980s, the concept of Advanced Nurse Practitioner (ANP) began to be defined and discussed extensively in the literature. In 1983, Harriet Kitzman, an associate professor at the University of Rochester, explored the interrelationships between Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs). She used the term “advanced practice” throughout her discussion, applying it not only to advanced education but also to CNS and NP practice. Kitzman noted:

“Recognition for advanced practice competence is already established for both NPs and CNSs through the profession’s certification programs. … advanced nursing practice cannot be setting-bound, because nursing needs are not exclusively setting-restricted” (Kitzman, 1983, pp. 284, 288).

In 1984, Joy Calkin, an associate professor at the University of Wisconsin–Madison, proposed a model for advanced nursing practice. She specifically identified CNSs and NPs with master’s degrees as Advanced Practice Registered Nurses (APRNs).

Organizational Efforts and Integration

During the 1980s, significant efforts were made to explore the commonalities between the roles of CNSs and NPs:

  • The Council of Primary Health Care Nurse Practitioners and the Council of Clinical Nurse Specialists began examining their shared roles.
  • In 1988, these councils conducted a survey of all NP and CNS graduate programs, identifying considerable overlap in curricula.
  • Between 1988 and 1990, discussions about a merger took place, leading to the formation of the Council of Nurses in Advanced Practice in 1991.

Key Developments

  1. 1988-1990: Discussions and survey about merging roles.
  2. 1991: Formation of the Council of Nurses in Advanced Practice.

Despite the short-lived merger due to the restructuring of the American Nurses Association (ANA) in the early 1990s, this was a pivotal step in the organizational coalescence of advanced practice nursing.

Evolution of Advanced Nurse Practitioner Terminology

By the mid-1990s, the nursing literature increasingly used the term Advanced Nurse Practitioner to reflect an integrative vision of advanced practice. The first edition of this textbook, published in 1996, included Certified Registered Nurse Anesthetists (CRNAs) and Certified Nurse Midwives (CNMs) under the umbrella of advanced practice nursing.

Important Milestones

  • 1996: Publication of the first edition of the textbook, including CRNA and CNM roles.
  • Late 1990s: Increasing use of the term Advanced Nurse Practitioner in the literature.

The evolution of the Advanced Nurse Practitioner concept highlights the ongoing development and integration within the nursing profession.

Support From Physicians for Advanced Nurse Practitioners

Support From Physicians for Advanced Nurse Practitioners

Increasing Acceptance Among Physicians

Despite resistance within the nursing profession, physicians have increasingly accepted Advanced Nurse Practitioners (ANPs) in individual healthcare practices. In these local practices, ANPs and MDs established collegial relationships, negotiating work boundaries and reaching agreements about their collaborative practice.

Negotiations in the ANP-MD Dyad

In the ANP-MD dyad, negotiations centered on the ANP’s right to practice essential parts of traditional medicine, including:

  • Performing physical examinations
  • Eliciting patient symptoms
  • Creating diagnoses
  • Formulating treatment options
  • Prescribing treatment
  • Making decisions about prognosis

(Fairman, 2002, pp. 163–164)

Importance of Proximity and Supervision

The proximity of a supervising physician was considered key to effective practice, and on-site supervision was the norm. Grassroots acceptance of the ANP role depended on tight physician supervision and control of the protocols under which ANPs practiced. This supervision benefitted newly certified, inexperienced ANPs. According to Corene Johnson:

“Initially, we had to always have a physician on site. … I didn’t resent that. Actually, I needed the backup” (Fairman, 2002, p. 164).