I: FOUNDATIONS OF ADVANCED NURSING PRACTICE
OVERVIEW OF ADVANCED PRACTICE REGISTERED NURSING
Advanced practice registered nurses (APRNs) are at the forefront of the rapidly changing health care system, filling myriad roles in organizations where they provide cost-effective, high-quality care. APRNs are found in virtually every area of the American health care system: clinics, hospitals, community health, government, administration, policy making boards, and private practice. In addition, APRNs have expanded practice into international and trans-global arenas. They serve the most economically disadvantaged as well as the elite. APRNs are deans, educators, consultants, researchers, policy experts, and, of course, outstanding clinicians.
Advanced practice registered nursing is an exciting career choice with many opportunities and challenges. The challenges are sometimes related to health care reform that is polarized and responsive to rapidly evolving political influences. Prospective payment systems, decreased hospital stays, health inequities, and spiraling costs are daily APRN practice realities. Technology produces amazing diagnostic and treatment results; genetic research is unraveling complex pathophysiology; and sophisticated "big data" electronic infrastructures change the way information is gathered, stored, analyzed, and shared. Innovative care models are common and include home health care programs, integrated or complementary modalities, and retail clinics. These and other trends result in a rapidly changing health care system, ready for the influence and influx of APRNs.
Graduate education prepares APRNs to be key players in these complex systems. Midrange nursing theories provide strong conceptual foundations for APRN practice and nurse scholars. Nursing research uncovers scientific evidence for best practice, and research utilization skills enable APRNs to bring fresh ideas and proven interventions to health care consumers.
Complex reimbursement policies and mechanisms require that APRNs navigate reimbursement, management, and health policy regulations. Although APRNs were traditionally educated to provide advanced nursing care in specific clinics or hospital units, they now often work across system boundaries as they follow their patients through transitions of care. For example, APRNs care for patients in outpatient clinics, admit them to the hospital, assist in coordinating discharge plans, and collaborate with long-term care organizations, perhaps working with public health agencies to return their patients to their home communities. These new cross-system care models result in regulatory complexity for APRNs. They must be able to legally provide care across systems. Working across state lines results in even more issues because each state has its own laws and rules. In addition, each health care organization can interpret state and federal laws and regulations in its own professional staff policies. Organizations can be more restrictive than laws, but they cannot be less restrictive. Given considerable variations among practice environments, APRNs must be experts and proactive in the business and regulatory policies and processes. Staying current is best accomplished by participation in role-specific APRN professional organizations.
ADVANCED PRACTICE REGISTERED NURSING: THEN AND NOW
Advanced specialization of nurses beyond their formal entry-level education has a long and proud history of many innovative risk takers and key events. To capture that history and unify the advanced nursing specialists, the term advanced practice registered nurse (APRN) became the common umbrella term used to designate four specialty roles of nurses with formal postbaccalaureate preparation: certified nurse-midwives (CNMs), certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs).
Nurse anesthetists and nurse-midwives organized nearly a century ago and were the first APRNs to develop national standards for educational programs, professional organizations, and certification. NPs and CNSs standardized their preparation, certification, and licensing incrementally in recent decades. Various scholars and professional organizations have documented the unique history of each APRN role.
A number of factors led nursing leaders to delineate these four APRN roles. A critical factor was obtaining legal status to be directly reimbursed for their nursing services, a gradual process first achieved by nurse-midwives more than 30 years ago and subsequently expanded through federal and state legislation for the other three roles. Reimbursement laws and regulations require that nursing be able to specify the qualifications of these reimbursable APRNs, which contributed to increased standardization of titling, education, and national certification.
Public protection was another factor that led to the delineation of the APRN roles. State boards of nursing are mandated by state legislatures to safeguard the public from unsafe practice, and over time, all states have implemented laws and regulations to ensure that nurses in the four roles have specific expertise and skills. Some states have accomplished this through a second-level licensure process. In other states, APRNs are regulated through title protection and scope of practice laws. In 2008, APRNs reached an agreement defining a desired national model of regulation for the United States. This agreement, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education, is known as the LACE model (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). By mid-2014, the LACE model had been enacted in 19 states through complex legislative initiatives (Kopanos, 2014). Most other states' APRN groups are working toward amending state nurse practice laws by adopting the LACE model of regulation.
A final factor influencing APRN standardization has been the adoption of national APRN curricular guidelines and program standards. These standards were developed by many specialty organizations and brought through negotiations to consensus by nursing organizations such as the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), and the National Organization of Nurse Practitioner Faculties (NONPF). APRN educational standards have been endorsed by numerous nursing specialty organizations in the past decade and are used for national program accreditation.
Nursing's Scope and Standards of Practice (ANA, 2010) defines APRNs as having advanced specialized clinical knowledge and skills through master's or doctoral education that prepares them for specialization, expansion, and advancement of practice. Specialization is concentrating or limiting one's focus to part of the whole field of nursing. Expansion refers to the acquisition of new practice knowledge and skills, including knowledge and skills legitimizing role autonomy within areas of practice that overlap traditional boundaries of medical practice. Advancement involves both specialization and expansion and is characterized by the integration of theoretical, research-based, and practical knowledge that occurs as part of graduate education in nursing. This APRN definition, which is regulated by state and federal laws, does not include nurses with advanced preparation for administration, education, public health or research; those roles are considered "advanced nursing practice" and are not regulated, a fine but important legal distinction.
APRNs are educated within master's or doctoral nursing programs. Although CNSs have always required master's nursing degrees, in the past nurse-midwives, nurse anesthetists, and NPs were not all prepared in graduate nursing programs. Now, however, NPs must receive their education in graduate master's or clinical doctoral programs in nursing. CRNAs are prepared in graduate programs, although the master's degree does not necessarily have to be in nursing. Although the majority of CNMs are prepared in graduate nursing programs, some nurse-midwifery programs are located in health-related professional schools.
Because of their unique historical underpinnings, members of each APRN category have strong allegiance to their titles and their professional organizations. At times, this allegiance has been a barrier to the development of consistent language regarding APRN roles because each group has developed its own education, history, and titles. However, significant progress continues to be made in identifying commonalities.
Research-based practice (sometimes called evidence-based practice) is a key characteristic of APRN practice. Clinical doctoral nursing programs emphasize and expand the utilization of evidence-based practice, especially in terms of preparing APRNs to be organizational change agents.
Through a consensus-building process, the AACN formulated auricular elements for graduate APRN education (AACN, 2011), specifying the content of the graduate core curriculum and the advanced practice nursing core curriculum in master's programs (Exhibit 1.1). Practice doctoral nursing programs are based on the Essentials of Doctoral Nursing Education for Advanced Practice Nurses (AACN, 2006; Exhibit 1.2). The role-specific professional nursing organizations have further delineated specialized core competencies; documents are readily available on their websites and are frequently updated.
The core clinical content requires advanced health and physical assessment, advanced physiology and pathology, and advanced pharmacology (often referred to as the three Ps). These courses must be taught across the life span, with additional specific content required for students in each specialty area. For example, nurse-midwifery students need additional content on assessment of pregnant women and newborn infants, nurse anesthetist students require extensive content on anesthetic agents, and psychiatric/mental health students need additional content on antipsychotic medications.
Exhibit 1.1 ESSENTIAL ELEMENTS OF MASTER'S CURRICULUM FOR ADVANCED PRACTICE NURSING
I. Background for Practice From Sciences and Humanities
II. Organizational and Systems Leadership
III. Quality Improvement and Safety
IV. Translating and Integrating Scholarship Into Practice
V. Informatics and Healthcare Technologies VI. Health Policy and Advocacy
VII. Interprofessional Collaboration for Improving Patient and Population Health Outcomes
VIII. Clinical Prevention and Population Health for Improving Health
IX. Master's-Level Nursing Practice
Source: American Association of Colleges of Nursing (2011).
Exhibit 1.2 ESSENTIALS OF DOCTORAL EDUCATION AND COMPETENCIES FOR ADVANCED NURSING PRACTICE
I. Scientific Underpinnings for Practice
II. Organizational and Systems Leadership for Quality Improvement and Systems Thinking
III. Clinical Scholarship and Analytical Methods for Evidence-Based Practice
IV. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care
V. Health Care Policy for Advocacy in Health Care
VI. Interprofessional Collaboration for Improving Patient and Population Health Outcomes
VII. Clinical Prevention and Population Health for Improving the Nation's Health
VIII. Advanced Practice Nursing
Source: American Association of Colleges of Nursing (2006).
There are also professional ethics standards for APRNs. In addition to issues related to confidentiality and relationships, APRNs must provide support to patients and families in making ethical decisions related to treatment options (ANA, 2013). Although ethical issues appear to be more prominent in tertiary care settings, issues such as abuse and neglect are present in all settings. APRNs are frequently called on to work with professional colleagues, patients, and families to resolve ethical dilemmas.
All APRNs collaborate with other health professionals. Collaboration is a standard of ARPN care and is also referenced in state and federal law. Functioning on interdisciplinary teams or working in teams with other health professionals, APRNs need to clearly identify their unique contributions to patient outcomes. APRNs also collaborate with patients and their families in planning care and making decisions about the most acceptable treatments.
One emerging area of scholarship emphasizes APRN care outcomes (Kapu & Kleinpell, 2012), especially essential in this era of health care reform. A new term is comparative effectiveness research (CER), promoted by the Agency for Healthcare Research and Quality (AHRQ) and the Institute of Medicine (IOM). Given their history of cost-effectiveness, good patient satisfaction, and high-quality outcomes, APRNs should fare well in CER studies focused on APRN care models and outcomes. A critical review of relevant APRN outcomes research (Newhouse et al., 2011) is a milestone document that summarizes nursing effectiveness and APRN-sensitive indicators of care quality.