Nerve tension is pain that occurs because a nerve is being compressed or stuck in its surrounding tissue which prevents it from moving within its tract like it normally does. This can happen for a variety of reasons. If a joint has been immobile for a period of time it increases the risk that a nerve can get a little stuck
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).
| Aspect | Details |
|---|---|
| Year Established | 2008 |
| Primary Focus | Credentialing and regulation of APRNs |
| Key Components | Definitions of roles, titles, population foci, specialties |
| Four APRN Roles | Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), Certified Nurse-Midwife (CNM) |
| Six Population Foci | Family/Individual across the lifespan, Adult/Gerontology, Neonatal, Pediatrics, Women’s Health/Gender-related, Psychiatric/Mental Health |
| Licensure Requirements | Based on educational preparation and population focus |
| Certification Requirements | Must align with area of study |
| Regulatory Processes | Licensure, 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).
| Aspect | Details |
|---|---|
| Direct Care Provision | Mandatory for all APRN roles |
| Core Competencies | Must be developed by each APRN role |
| Educational Requirements | Advanced physiology and pathophysiology, health assessment, pharmacology |
| Specialty Certification | Not a basis for licensure; additional knowledge in discrete areas |
| Regulatory Processes | Must 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.
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
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:
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.
| Information | Details |
|---|---|
| Scope of Practice | Diagnosing and treating illnesses, prescribing medications, managing patient care |
| Settings | Hospitals, clinics, private practices |
| Role Differences | Expanded scope compared to traditional nurses, similar to physicians in many respects |
| Required Knowledge and Skills | Advanced clinical training, strong diagnostic skills, ability to prescribe medications |
| Patient Outcomes | Improved patient satisfaction, better health outcomes, cost-effective care |
| Healthcare Systems | Employ APNs to address shortages, improve quality of care, reduce costs |
| Patient Benefits | Enhanced care for complex conditions, better management of chronic diseases |
| Addressing Diversity | Focus on social determinants of health, culturally competent care |
| Model Revisions | Continuous updates to reflect evolving healthcare needs |
For more detailed information, refer to ANCC.
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).
APNs practice in diverse settings, each offering unique opportunities and challenges:
APNs differ from other healthcare providers in several ways:
APNs require a diverse set of knowledge and skills:
The outcomes of care delivered by APNs are significant and well-documented:
Healthcare systems benefit from employing APNs in various ways:
APNs are integral in solving many pressing healthcare issues:
Conceptual models in APN are essential for guiding practice and education:
By clearly defining the phenomenon and related concepts, these models ensure consistency and effectiveness in advanced practice nursing.
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.
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.
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.
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.
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.
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.
By addressing these issues, the conceptualization of advanced nurse practitioner roles can be clarified, enhancing the understanding and practice of APRNs globally.
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).
Fawcett and Desanto-Madeya (2013) described a conceptual model as:
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).
Evolving a more uniform and explicit conceptual model for advanced practice nursing benefits patients, nurses, and other stakeholders by:
This systematic approach enhances nursing research, education, administration, and practice (Institute of Medicine, 2011).
Conceptual models help Advanced Nurse Practitioners (ANPs) articulate professional role identity and function. These models serve as frameworks for:
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).
Conceptual models differentiate among levels of nursing practice, such as:
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.
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).
Fawcett and Graham (2005) and Fawcett et al. (2004) have posed important questions about advanced practice:
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).
Healthcare legislation changes and regulations emphasize the need for ANPs to be explicitly engaged in delivering care across settings, including:
Theoretical questions about the conceptualization of advanced practice nursing include:
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.
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.
1990s Growth:
Master’s and Post-Master’s Programs:
Since 2015, there has been rapid growth in DNP programs for ANP education nationwide.
Clearly, the trend nationwide is toward the DNP as the requirement for ANP practice.
Historical Background
New Responsibilities
Residency Shortages
Complex Tertiary Care Systems
Early Academic Efforts
Program Proliferation and Consensus
Certification and Integration
Increasing Appeal of the NP Role
Organizational Developments
Unified Representation
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.
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:
By 1984, approximately 20,000 graduates from ANP programs were employed in various settings envisioned by the founders (Kalisch & Kalisch, 1986, p. 715):
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).
The multiple roles of ANPs created competing interests, impacting their ability to unify on legislative issues. Key organizational developments included:
Federal legislation in the early 1990s, particularly the Controlled Substances Act, significantly impacted ANP prescriptive authority:
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.
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.
The fight for prescriptive authority for Advanced Nurse Practitioners (ANPs) spanned the latter decades of the 20th century.
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.
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.
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.
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).
During the 1980s, significant efforts were made to explore the commonalities between the roles of CNSs and NPs:
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.
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.
The evolution of the Advanced Nurse Practitioner concept highlights the ongoing development and integration within the nursing profession.
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.
In the ANP-MD dyad, negotiations centered on the ANP’s right to practice essential parts of traditional medicine, including:
(Fairman, 2002, pp. 163–164)
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).