Role of the Advanced Practice Nurse in the US

• Shawn Blankenship

Introduction

Today, the American healthcare system faces many challenges to provide adequate healthcare. As the country’s population grows, coupled with the passing of the Affordable Care Act, the country not only has a shortage of healthcare providers, but now has the increased responsibility to provide coverage to those previously without affordable healthcare. Advanced Practice Nurses (APNs), a group of highly qualified, educated clinicians are ready to play integral roles in the reform of healthcare. Unfortunately, because APN regulation is determined on the state level, the scope of practice for APNs varies state to state. Consequently, national unpredictability, both administratively and legislatively creates an unfavorable environment for APNs to provide consistent, proper care. The following paper will attempt to not only provide a brief history regarding the development of the APN, but additionally review the roles of the four recognized general areas of APN specialization. Furthermore, each APN role will not only be expanded upon such to differentiate, but compared and contrasted, as well as analyzed from a local, state, national, and international perspective such to conclude by providing assertions regarding the current state of the advanced nursing practice.

History of APN

All APN roles have a long history in healthcare; certified nurse anesthetists (CNAs) were introduced in the late 1870s, certified nurse practitioners (CNPs) in the 1960s, certified nurse midwives (CNMs) in the early 1920s, and the clinical nurse specialist (CNSs) role developed in the late 1940s. However, even though APNs have had well recognized roles in medicine for well over a century the officially recognized APN role originated in the 1960s. Ironically, as history often repeats itself, the APN role emerged due to a shortage of primary care physicians that coincided with the expansion of national healthcare coverage. With the initiation of Medicare and Medicaid, the first APN program was developed at the University of Colorado in 1965 by Professors Loretta Ford, PhD,

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RN and Henry Silver, MD to prepare pediatric APNs to focus on health and wellness. Working together with physicians, APNs were taught to not only identify symptoms, but to diagnose and manage the healthcare problems in children. In the 1970’s the program’s focus changed to primary care such to provide primary healthcare access for large and underserved populations. In 1971, the Secretary of Health, Education and Welfare issued primary care intervention recommendations whereas nurses and physicians could now share responsibility, implying support for nurses. Subsequently, federal monies were made available to support APN programs nationally. By the mid-1970’s, at one point therewere in excess of over 500 certificate programs which then shifted to Master’s Degree programs in the 1980’s as accrediting bodies required enhanced education. The Balanced Budget Act of 1997 included the Primary Care Health Practitioner Incentive Act, perhaps the most important payment reform to affect advanced practice nurses allowing direct Medicare reimbursement to the APRN, but at 85% of the physician fee rate. Graduate education prepares APNs to be key players in the most complex of systems, and nursing theory provides APNs with a strong conceptual base for practice. Furthermore, as nursing research uncovers evidence to utilize skills enabling APNs to bring fresh ideas and proven interventions to health care consumers; now, complex, evolving reimbursement requires the APN to also be educated in financial management and health policy issues. Unfortunately, for continued growth related to reimbursement the APN faces the lack of third-party reimbursement, prescriptive ability, and hospital admission privileges whether acting as part of a team, or collaboratively.

An APN is a not only a registered nurse, but a nurse that has completed at least a graduate level of education, is certified by a nationally recognized certifying body, and is also recognized as APN in one’s state. Today, the current APN educational curriculum not only focuses on the attainment of key competencies (American Academy of Nurse Practitioners) but also includes pathophysiology, health assessment, pharmacology, and clinical diagnosis and treatment. This

education prepares the APN to diagnose, treat, and prescribe. Furthermore, APNs must demonstrate a dedication to learning and are required to obtain continuing education in order to maintain their national certification. As of 2000, APNs were legally recognized to practice, to some capacity, in every state throughout the United States, and are utilized internationally, too.

Comparison and Contrast of APN Roles

Certified Nurse Practitioners (CNPs)

Although nationally recognized through several professional certification boards, a CNP’s scope of practice is regulated by one’s individual state board of nursing. Subsequently, employment can be found locally through a myriad of choices that is restricted only by one’s scope of practice,

and/or the working relationships that are established in one’s healthcare community, and/or in one’s setting of choice for employment. CNPs perform comprehensive assessments and promote health and the prevention of illness and injury. Additionally, they diagnose, develop differentials, and interpret diagnostic and laboratory tests, order, conduct, and supervise. CNPs are also able to prescribe pharmacologic and non-pharmacologic treatments in the direct management of acute and chronic illness and disease. From providing health and medical care in primary, acute, and long-term care settings, CNPs can serve in various settings as researchers, consultants, and patient advocates for individuals, families, groups and communities. Additionally, CNPs may specialize in areas such as family, geriatric, pediatric, primary, or acute care to name a few.

Nevertheless, depending on the state, CNPs can practice autonomously and/or in collaboration with other healthcare professionals to treat and manage patients’ health programs. Currently, eighteen states and the District of Columbia allow CNPs to practice and prescribe independently (without any direct physician supervision or collaboration). The remaining states regulate NP practice with requirements such as direct physician supervision for diagnoses, treatment and/or prescriptive authority. Relative to CNMs and CNAs, CNPs have a relatively short history in the

health care delivery system. Internationally, CNP’s roles have yet to reach the development that they have in the United States, with few countries affording the role, or confused with how to progress.

Certified Nurse Anesthetists (CNAs)

Certified nurse anesthetists (CNAs) are registered nurses who have received specialized education in the field of anesthesia. Similar to CNPs, even though CNAs are nationally recognized through professional certification boards, the scope of their practice is regulated by each individual CNA’s state board of nursing. Moreover, depending on the individual’s state requirements, CRNAs are occasionally regulated through the federal government’s Centers for Medicare and Medicaid. Ironically, even though no state statute requires anesthesiologist supervision of CNAs, the Centers for

Medicare and Medicaid (CMS) state in their rules for participation that CNAs must be supervised by a physician. In 2001, CMS amended this requirement by providing an opt-out or exemption ruling. To date, sixteen state governors have requested and received exemption from the CMS, the point being in many rural hospitals is that the only person on staff for anesthesia is the CNA. CNAs nationally, statewide, and locally provide anesthetics before and after surgical, obstetric, and therapeutic procedures; they practice in hospitals, ambulatory surgical centers and dental offices and are often the sole anesthesia providers in many rural hospitals (AANA). Moreover, internationally, CNAs are very widely used. Where CNP and CNS roles are still developing, CNAs are presently utilized in greater than half of the world’s nearly two hundred countries.

Clinical Nurse Specialists (CNSs)

Clinical nurse specialists, similar to CNPs, are nationally recognized through professional certification boards, and a CNS’s scope of practice is regulated by one’s individual state board of nursing. The CNS role affords tremendous diversity within the title. Nationally, statewide, or locally, a CNS can provide advanced nursing care in acute care facilities such as hospitals, provide acute and chronic care management, develop quality improvement programs, mentor and educate staff, or work as a researcher or consultant. The CNS role was based on the premise care is

interrelated, that patient care would improve when advanced practitioners with specialized knowledge and skills are there to create environments that foster caring and problem solving on multiple spheres: patient, nurse, and system (National Council of State Boards of Nursing). Internationally, CNSs continue to develop as APNs, similar to the CNP. Currently, CNSs are seen as healthcare promoters and problem solvers.

Certified Nurse Midwives (CNMs)

CNMs, certified through rigorous national examinations, similarly to the three previously mentioned APN roles, have their scope of practice regulated by each state’s board of nursing (American College of Nurse and Midwives, 2010). CNMs provide primary care for women, adolescence through menopause, and beyond. CNMs focus on reproductive healthcare including health promotion, pregnancy, childbirth, postpartum, family planning and gynecological care (American College of Nurses and Midwives, 2008). In providing primary care, CNMs prescribe medications, order laboratory and other diagnostic testing, offer health education and counseling and collaborate with other healthcare providers. Nationally, statewide, and locally CNMs work in hospitals, birthing centers, community clinics, and in patient homes one on one. Internationally, CNMs similarly to CNAs have been utilized for decades, throughout 80 countries.

Analysis of Advanced Practice Nursing Current State

Certified Nurse Practitioners (CNPs)

NPs are highly skilled at providing comprehensive assessments resulting in clinical decision making

that is safe and cost effective. Nurse practitioners have favorable outcomes in acute care by reducing length of stay and hospital-associated costs (Carruth & Carruth, 2011).

Reductions in healthcare costs are associated with APRN directed care, as evidenced in a recent study showing annual cost reductions from $5,210 to $3,061 among chronically ill patients (Meyer, 2011).

Settings such as hospitals Fully utilized APRNs offer primary and specialty care and can reduce costs to the system (Chen, et al., 2009).

In the over 40 year history of the NP profession, a multitude of studies have demonstrated that NPs have performed as well as physicians caring for similar patients with respect to health outcomes, proper diagnosis, management, and treatment (Newhouse, et al., 2011).

Certified Nurse Midwives (CNMs)

in the Appalachian Mountains of Kentucky the nurse midwife model of care emerged. Here, the Frontier Nursing Service provided community-based care to disadvantaged pregnant women, children, and families. (Ernst & Stone, 2013).This historical perspective demonstrates that CNMs have always provided safe, quality care. Low-risk women are routinely subjected to medical interventions, many of which are unsupported in research as beneficial, such as continuous fetal monitoring, induction of labor, intravenous therapy, epidural anesthesia, and elective cesarean births. Pregnant women cared for by CNMs are less likely to undergo invasive interventions, which reduce health care costs without sacrificing quality (Johantgen et al., 2012). Finally, CNMs deliver care that is similar to that provided by physicians and CNMs have lower rates of cesarean sections, lower epidural use, and lower labor induction rates; while, maintaining infant and maternal outcomes (Newhouse, et al., 2011)

Clinical Nurse Specialist (CNSs)

Clinical nurse specialists are experts in their specialties. The costs of managing chronic illness decrease when a CNS is involved in management of the patient. Research supports the utilization of a CNS as part of the interdisciplinary team to lower hospital costs and improve the outcomes of patients with chronic illness (Moore & McQuestion, 2012). Implementation of the CNS role is associated with improvement in patient outcomes (Newhouse, 2011).

Certified Nurse Anesthetist (CNAs)

certified registered nurse anesthetists (CRNAs) provide safe, high-quality anesthetic care. Currently, 70% of all anesthetics in rural hospitals are safely delivered by CRNAs (Gardner et al., 2011)

Research has not shown that patient care, safety or quality compromised when a CRNA practices without physician oversight. In addition to education and training costs, CRNAs practicing independently can provide anesthesia services at 25% lower costs (Jordan, 2011).

CRNAs are associated with equivocal complication and mortality rates when contrasted with physicians (Newhouse, et al., 2011).

International APN

Pulcini, Jelic, Gul, & Loke (2010).

Sangster-Gormley, Martin-Misener, Downe-Wamboldt, & DiCenso (2011).

Conclusion

Advanced practice nurses find themselves caught within an incredibly complex situation. As the country faces new, expanded challenges for access to healthcare, APNs have continued to not only increase their qualifications and provide evidentiary support such to establish a federally regulated, nationally recognized platform regarding autonomy, but stand ready to act. Unfortunately, barriers that exist both administratively and legislatively due to a lack of consistency in state to state scope continue to delay long-awaited healthcare relief for our citizenry, as well as professional consistency amongst APNs, too. This paper presented a brief history regarding the APN, as well as a review of APN roles from a national, state, local, and international perspective. Additionally, this paper compared and contrasted the roles of the APN while drawing assertions to the current state of the advanced practice nurse. In conclusion, presented examples regarding the qualifications of the APN roles are obvious; however, the barriers identified reinforce the overwhelming need for immediate change.

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