MULTIFACETED ROLES OF THE APRN
Before delving into the various roles of the advanced practice registered nurse (APRN), the impact of the Patient Protection and Affordable Care Act (Public Law 111-148,2010), and the Health Care and Education Afford-ability Reconciliation Act (Public Law 111-152) on the APRN role will be reviewed. These laws will be collectively referred to as the Patient Protection and Affordable Care Act (АСА) in this chapter. The АСА was signed into law on March 23, 2010. This comprehensive health care legislation is the biggest change in the United States health care system since the creation of Medicare and Medicaid programs in 1965. The АСА is anticipated to provide insurance coverage for an additional 32 million previously uninsured Americans. This new regulation has left the U.S. health care system in an uproar regarding reimbursement, access to care, and lack of health care providers. These new issues reflect that some major changes need to occur in the current system in order to cost-effectively provide care to an increased patient population. The changes associated with the implementation of the АСА have provided an opportunity for APRNs to remove legislative and regulatory barriers and become major players in the redesign of the health care system.
The implementation of the АСА (2010) has created a necessity for the doctorate of nursing practice (DNP)-prepared APRN. The DNP degree focuses on preparing APRNs not only for practice but also to be leaders in practice improvements. The DNP interprets original research into clinical application, health policy changes, and improvement of clinical outcomes with interdisciplinary collaboration (American Association of Colleges of Nursing [AACN], 2006). The АСА includes provisions for strengthening primary care, ensuring quality care, and reducing the costs associated with health care. DNP-prepared APRNs can use their practice background and systems thinking to initiate new processes and policies to better serve the potential increased number of patients. The public has also been enlightened to the role of the APRN in health care delivery via the Institute of Medicine's (IOM's) report on the future of nursing (Committee for the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). Whether it be the certified nurse practitioner (CNP) in an underserved area, the certified nurse-midwife (CNM) providing access to obstetric care, the certified registered nurse anesthetist (CRNA) providing a cost-effective solution to anesthetic care, or the clinical nurse specialist (CNS) maximizing the specialty care provided at the patient bedside, APRNs are poised to be forces of change in the future of health care.
Traditionally, the roles of the APRN have been clinically focused, as clinician, patient advocate, case manager, consultant, and collaborator, to name a few. Other roles have been underlying for many years, but more recently these have pushed into the limelight. These are the roles of leader, educator, researcher, and independent clinician. Ultimately, the APRN's foundation is that of a clinician—and always will be. With health care reform, we need to keep our clinical roots but must expand to best serve our patients and profession. This chapter will examine the various roles, focusing on incorporating them into the whole and consummate professional.
APRN ROLES
Several APRN nursing models have reviewed and researched roles for this growing profession. Hamric's integrative model of advanced nursing practice is a very comprehensive model that includes primary criteria for the APRN as well as central and core competencies (Hamric, Spross, & Hanson, 1996). Primary criteria included in this model are graduate education, certification in the specialty, and a focus on clinical practice. Core competencies referenced by Hameric et al. are direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, and leadership. This model also incorporates outside elements affecting APRN practice. A framework for advanced practice nursing developed by Brown (1998, 2005) looked at the external issues, roles, APRN scope and competencies, as well as outcomes of APRN role. One model, the Strong Model of Advanced Practice (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996), is one of the few that has been tested for validity (Mick & Ackerman, 2000). This model has also been supported throughout the literature and used in other research, such as the development of a role-delineation tool by Chang, Gardner, Duffied, and Ramis (2012).
The Strong Model breaks down APRN roles by service parameters. These parameters include direct comprehensive care, support of systems, education, research, and publication and professional leadership. This model, with some modification, is used to further define APRN roles in this chapter.
