Professional Roles for the Advanced Practice Nurse

PART 1

Professional Roles for the Advanced Practice nurse

The chapters in Part 1 of this book consider nursing that reflects current thinking. As the role of the advanced practice nurse you read this chapter, keep in mind this from historical, present-day, and future expanded definition and appreciate the perspectives. This content is intended to development of the advanced clinical roles serve as a general introduction to select for nursing practice. This discussion lays issues in professional role development for the foundation for a deeper understand- the advanced practice of nursing. As stu- ing of the historical development, current dents progress in the educational process practice, and future opportunities for and develop greater knowledge and exper- advanced practice in nursing. tise, role issues and role transition should In Chapter 2, Stewart discusses the tip- be integrated into the entire educational ping point for nurse practitioners as we program. enter the age of healthcare reform and the In Chapter 1, the editors define role nurse practitioners will play in provid- advanced practice nursing from a tradi- ing cost-effective, quality primary care to tional perspective and trace the history a demographically changing population. of the role. Traditionally, advanced prac- Stewart’s quantitative and qualitative tice has been limited to clinical roles that research resulted in the Stewart Model include the clinical nurse specialist, nurse of Nurse Practitionering that reflects key practitioner, certified nurse-midwife, and attributes that make nurse practitioners certified registered nurse anesthetist; unique. Much has transpired related to the to practice, the last three roles require a role and education of nurses for advanced license beyond the basic registered nurse practice. Most revolutionary is the man- (RN) license. This book, however, uses an date to have by 2015 the clinical doctorate expanded definition of advanced practice be the required degree for advanced clinical

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practice nursing (American Association of Col- For other advanced practice roles, includ- leges of Nursing, 2004). With this change, many ing those of the clinical nurse leader, nurse master’s programs for advanced practice nurses educator, and nurse researcher, a different set will transition to the doctoral level. The ratio- of educational requirements exists. The clini- nale for this position by the American Associa- cal nurse leader as a generalist remains a mas- tion of Colleges of Nursing (AACN) is based on ter’s-level program. For nurse educators, the several factors: position of AACN—although not universally accepted within the profession (as demon- ■■ The reality that current master’s degree programs often require credit loads equiva- strated by the existence of master’s programs lent to doctoral degrees in other healthcare in nursing education)—is that didactic knowl- professions edge and practical experience in pedagogy are additive to advanced clinical knowledge. ■■ The changing complexity of the healthcare Nurse researchers will continue to be prepared environment in PhD programs. Thus, there will be only two ■■ The need for the highest level of scientific doctoral programs in nursing, the DNP and knowledge and practice expertise to ensure the PhD. It is important for readers to keep high-quality patient outcomes abreast of this movement as the profession fur- In an effort to clarify the standards, titling, ther develops and debates these issues because and outcomes of clinical doctorates, the Com- the outcomes have implications for their own mission on Collegiate Nursing Education practice and professional development within (CCNE)—the accreditation arm of AACN—has their own specialty. The best resource for this decided that only practice doctoral degrees is the AACN website and the websites of spe- awarding a Doctor of Nursing Practice (DNP) cialty organizations. will be eligible for accreditation. In addition, The next three chapters in Part 1 discuss the the AACN has published the Essentials of Doc- future of advanced practice nursing and the toral Education for Advanced Nursing Practice, evolution of doctoral education—in particular, which sets forth the standards for the develop- the practice doctorate. Within today’s rapidly ment, implementation, and program outcomes changing and complex healthcare environment, of DNP programs. members of the nursing profession are challeng- Needless to say, this recommendation ing themselves to expand the role of advanced has not been fully supported by the entire practice nursing to include highly skilled prac- profession. For instance, the American Orga- titioners, leaders, educators, researchers, and nization of Nurse Executives (AONE, 2007) policymakers. does not support requiring a doctorate for In Chapter 3, Chism defines the DNP degree managerial or executive practice on the basis of and compares and contrasts the research doc- expense, time commitment, and cost benefit torate and the practice doctorate. The focus of of the degree. It also suggests that nurses may the DNP degree is expertise in clinical practice. migrate toward a master’s degree in business, Additional foci include the Essentials of Doctoral social sciences, and public health in lieu of a Education for Advanced Nursing Practice as outlined master’s degree in nursing. Further, AONE sug- by the AACN (2004), which include leadership, gests there is a lack of evidence to support the health policy and advocacy, and information need for doctoral education across all aspects of technology. Role transitions for advanced prac- the care continuum. In contrast, doctoral and tice nurses prepared at the doctoral level call for master’s-level education for nurse managers an integration of roles focused on the provision and executives is encouraged. of high-quality, patient-centered care.

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In Chapter 4, White discusses emerging both barriers to successful collaborative teams roles of DNP graduates as nurse educators, and factors for successful team development. nurse executives, and nurse entrepreneurs and Advanced practice nurse leaders educated advanced practice nurses’ increased involve- at both the master’s and doctoral levels are ment in public health programming and inte- uniquely positioned to overcome the workforce grative and complementary health modalities. and regulatory issues that might otherwise In Chapter 5, Barker sets the foundation diminish the success of collaborative teams—in for advanced practice nurses to recognize and particular, those involving participants from embrace their role as leaders and influencers of the nursing and medicine disciplines. practice changes in healthcare organizations. Complexity science, organizational change the- References ory, and transformational leadership are used American Association of Colleges of Nursing (AACN). as a platform for advanced practice nurses to (2004). AACN position statement on the Doctorate in realize their leadership potential and their role Nursing. Retrieved from http://www.aacn.nche. as agents of change. edu/DNP/DNPPositionStatement.htm American Organization of Nurse Executives (AONE). Last, in Chapter 6, Ash and Miller provide (2007). Consideration of the Doctorate of Nursing an in-depth look at interdisciplinary and inter- Practice. Retrieved from http://www.aone.org professional collaborative teams as means to /resources/leadership%20tools/Docs/Position- effect positive health outcomes. They discuss Statement060607.doc

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introduction to the Role of Advanced Practice nursing susan deNisco and Anne Barker

cHAPteR oBJectiVes 1. describe the four roles used to define advanced practice nursing in the united states. 2. Identify the differences between the clinical nurse leader role and the traditional advanced practice nursing roles. 3. Recognize factors that currently influence the supply and demand of nurse educators.

INtROduCtION specialist (CNS). The first three roles require Considerable confusion exists regarding a license beyond the basic registered nurse the terminology advanced nursing practice , (RN) license. The role of the clinical nurse advanced nurse practice , and advanced prac- specialist requires a master’s degree but does tice registered nurse . Based on the definition not require separate licensing unless the given by the American Association of Col- CNS is applying for prescriptive authority. leges of Nursing (AACN) and other widely Complicating the titling and defini- accepted usages, the term advanced practice tion of roles, the AACN (2004) defined registered nurse (APRN) has been used to indi- advanced practice nursing as follows: cate master’s-prepared nurses who provide Any form of nursing intervention that direct clinical care. This term encompasses influences health care outcomes for the roles of nurse practitioner (NP), certified individuals or populations, including nurse-midwife (CNM), certified registered direct care of individual patients, nurse anesthetist (CRNA), and clinical nurse management of care for individuals and

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populations, administration of nursing and nurse (APRN). APRNs are educated in one of health care organizations, and the development the four roles and in at least one of the follow- and implementation of health policy. (p. 2) ing population foci: family/individual across The Consensus Model for APRN Regulation is a the life span, adult-gerontology, pediatrics, product of substantial work done by the APRN neonatal, women’s health/gender-related, and Consensus Work Group and the National Coun- psych/mental health (APRN Consensus Work cil of State Boards of Nursing (NCSBN) APRN Group & National Council of State Boards of Advisory Committee in an effort to address the Nursing APRN Advisory Committee, 2008) irregularities in regulation of advanced practice Advanced practice registered nurses are licensed registered nurses across states. As defined in independent practitioners who are expected to the model for regulation, there are four roles: practice within standards established or recog- certified registered nurse anesthetist, certified nized by a licensing body. The model further nurse-midwife, clinical nurse specialist, and cer- addresses licensure, accreditation, certification, tified nurse practitioner (CNP). These four roles and education of APRNs. Figure 1-1 depicts are given the title of advanced practice registered the APRN Regulatory Model.

figure 1-1 APRN Regulatory Model.

FPO

National Council State Board of Nursing: The APRN Consensus Model 2008

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Other Advanced Practice care delivery. The CNL is a provider and man- Nursing Roles and the Nursing ager of care at the point of care for individuals Curriculum and cohorts of patients anywhere healthcare is delivered (AACN, 2007). In fact, as recom- Consequently, nurse administrators, public mended in the AACN white paper on the CNL health nurses, and policymakers are consid- role, all CNL curricula across the country ered advanced practice nurses albeit they do require graduate-level content that builds on not provide direct care or obtain advanced an undergraduate foundation in health assess- practice licensure per the state they practice in. ment, pharmacology, and pathophysiology. In As this book goes to press, there is an initia- many master’s-level programs, NP and CNL tive to expand and clarify the definition of and students sit side by side to learn these advanced requirements for advanced practice nursing. No skills. Also, the inclusion of these three sepa- matter the final outcome of this deliberation, rate courses—health assessment, pharmacol- all nurses need the same set of essential knowl- ogy, and pathophysiology—facilitates the edge. The Essentials series outlines the necessary transition of master’s program graduates into curriculum content and expected competencies Doctor of Nursing Practice degree programs of graduates of baccalaureate, master’s, and (AACN, 2007). Moreover, the CNL program doctoral nursing practice programs and the graduate has completed more than 400 clinical clinical support needed for the full spectrum practice hours, similar to number required of of academic nursing (AACN, 2006, 2011a, NP graduates, and is eligible to sit for the CNL 2011b). Although the terms advanced practice Certification Examination developed by the nursing, advanced practice nurses, advanced nursing American Association of Colleges of Nursing. practice, and advanced practice registered nurses are The clinical nurse leader, similar to the used interchangeably throughout this text, the clinical nurse specialist (discussed next), authors are addressing any students enrolled has developed clinical and leadership skills in master’s or doctoral programs that are and knowledge of statistical processes and designed, implemented, and evaluated by the data mining. The CNL brings evidence-based AACN Essentials. Chapter 2 provides an over- practice to the bedside, creates a culture of view of the master’s and doctoral essentials. safety, and provides quality care. This aligns directly with the American Organization of Clinical Nurse Leaders Nurse Executives (AONE) guiding principles Clinical nurse leaders (CNLs) were not consid- for the nurse of the future (Haase-Herrick & ered in the definition of advanced practice because Herrin, 2007). the CNL role did not exist when the aforemen- tioned roles were defined. Some argue that the Clinical Nurse Specialists CNL is a generalist, and thus CNL should not Clinical nurse specialists (CNSs) have been be considered an advanced practice role. The providing care to patients with complex cases authors disagree. The clinical nurse leader role across healthcare settings since the 1960s. requires advanced knowledge and skill beyond The CNS role originated largely to satisfy that attained with the baccalaureate degree, and the societal need for nurses who could provide it requires a master’s degree for certification. advanced care to psychiatric populations. Since According to the AACN (2007), the clini- the passage of the National Mental Health cal nurse leader is responsible for patient care Act in 1946, the National League for Nursing outcomes and integrates and applies evidence- (NLN) and the American Nurses Association based information to design, implement, and have supported the CNS role. The first pro- evaluate healthcare systems and models of gram at Rutgers University educated nurses

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for the role of psychiatric clinical specialist have a difficult time showing that CNSs (McClelland, McCoy, & Burson, 2013). Fol- decrease hospital costs, and they cannot bill lowing this implementation, the usefulness of for specialty nursing services. The AACN states the role became apparent, and schools of nurs- that there are significant differences between ing began to educate nurses across specialties, the CNS and CNL roles; however, few differ- including oncology, medical-surgical, pediat- ences are clearly articulated by those being ric, and critical care nursing. educated in or practicing in these roles or in The literature of the 1980s and 1990s shows recent documents created by AACN (National that care provided by clinical nurse specialists Association of Clinical Nurse Specialists produced positive patient outcomes related to [NACNS], 2005). This has created role confu- self-management and early hospital discharge sion and uncertainty regarding the role these (Fulton, 2014). More recently, studies show nurses should play in the inpatient hospital improvement in patient satisfaction and in setting. Table 1-1 compares role competencies pain management, and reduced medical com- of the CNS and the CNL. plications in hospitalized patients (McClelland In addition, the APRN Consensus Model et al., 2013). states that graduate nursing roles that do not The recent trend toward hospital and focus on direct patient care will not be eligible healthcare system mergers and the focus on for APRN licensure in the future (APRN Con- cost containment force the CNS role into a sensus Work Group & National Council of State precarious position. Hospital administrators Boards of Nursing APRN Advisory Committee,

Table 1-1 Comparison of Select Role Competencies for the CNS and the CNL

Clinical Nurse Specialist Clinical Nurse Leader Direct care Critical thinking/clinical decision making Assessment Systems leadership Nursing technology and resource management Collaboration Communication Coaching Consultation Research Assimilates and applies research-based information to design, implement, and evaluate client plans of care Ethical decision making, moral agency, Ethics and advocacy Accountability Professional values, including social justice Professional development Sources: American Association of Colleges of Nursing. (2007). White paper on the role of the clinical nurse leader. Retrieved from http://www.aacn.nche.edu/aacn-publications/white-papers/cnl-white-paper; National CNS Com- petency Task Force. (2010). Clinical nurse specialists core competencies: Executive summary 2006–2008. Retrieved from http://www.nacns.org/docs/CNSCoreCompetenciesBroch.pdf

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2008). This creates further challenges for the education should be directed toward enhanc- CNS, such as variability in state title protection, ing clinical expertise. According to the AACN inconsistency among states grandfathering in (2014), the master’s-level curriculum for the the CNS role, lack of a regulatory approach to nurse educator builds on baccalaureate knowl- accepting grandfathered CNSs to practice in edge, and graduate-level content in the areas of other states, and job loss based on mispercep- health assessment, pathophysiology, and phar- tions of the model (NACNS, 2005). macology strengthen the graduate’s scientific background and facilitate understanding of Nurse Educators nursing and health-related information (AACN, The role of nurse educators may be one of the 2014). In this model students are required to most contentious issues in nursing education. take courses beyond the graduate core curricu- According to the National League for Nursing lum and that provide content expertise in the (2002), the nurse educator role requires special- “3 Ps” (pharmacology, pathophysiology, and ized preparation, and every individual engaged physical assessment), similar to the education in the academic enterprise must be prepared of nurse practitioners and clinical nurse leaders. to implement that role successfully. Nurse On the other side of the argument, many clini- educators are key resources in preparing the cians who become nurse educators are already nursing workforce to provide quality care to clinical experts and are content experts. They meet the healthcare needs of a rapidly aging need the advanced degree to learn teaching/ and diverse population. Whether in academic learning theories and strategies, curriculum or clinical settings, nurse educators must be development, and student evaluation content. competent clinicians. However, whereas being a good clinician is essential, some would say it is Nurse Educator Supply and Demand not sufficient for the educator role. Much of the The Health Resources and Services Administra- debate in nursing education centers on the fact tion (HRSA) has projected a large increase in that the nurse educator student primarily needs demand for nurses, from approximately 2 mil- advanced knowledge and skills in clinical prac- lion full-time equivalents in 2000 to approxi- tice in order to teach, and therefore graduate mately 2.8 million in 2020. See Table 1-2.

Table 1-2 Supply, Demand, Shortage of Nurses

2000 2005 2010 2015 2020 Supply 1,890,700 1,942,500 1,941,200 1,886,100 1,808,000 Demand 2,001,500 2,161,300 2,347,000 2,569.800 2,824,900 Shortage (110,800) (218,800) (405,800) (683,700) (1,016,900) Supply ÷ 94% 90% 83% 73% 64% Demand Demand 6% 10% 17% 27% 36% shortfall Source: Data from U.S. Department of Health and Human Services, 2004.

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Meeting this projected demand will require a of clinical practice prior to being educated for significant increase in the number of nursing a faculty role. The idea of advanced practice graduates, perhaps by as much as 40%, to fill nurses with clinical doctorates versus research new nursing positions as well as to account doctorates working in academia has been sup- for attrition from an aging workforce. This ported by the National Organization of Nurse corresponds to an increase in the demand for Practitioner Faculties, NLN, and AACN. The nursing faculty. In 2008, approximately 13% Doctor of Nursing Practice degree may be the of the nation’s registered nurses held either answer to imparting advanced knowledge in a master’s or doctoral degree as their highest evidence-based practice, quality improvement, educational preparation (AACN, 2011b). The leadership, policy advocacy, informatics, and current demand for master’s- and doctorally healthcare systems to clinicians, managers, prepared nurses for advanced practice, clinical and educators. The DNP-prepared educator is specialties, teaching, and research roles far out- poised to educate a future nursing workforce that strips the supply. can influence patient care outcomes. The nurs- Consequently, to increase the supply requires ing faculty shortage contributes to the problem a major expansion of nursing faculty and other of nursing programs turning away qualified educational resources. With the “graying” of applicants across graduate and undergraduate the current pool of nursing faculty, efforts we programs. See Figure 1-2. make must persuade more nurses and nurs- This text addresses the essential content ing students to pursue academic careers, and that nurses pursuing advanced degrees need to to do so at an earlier age. Careers in nursing learn to prepare to be nurse educators. Com- education are typically marked by long periods petence as an educator can be established,

Figure 1-2 Faculty shortage.

Lack of faculty is main obstacle to expending capacity, 2012 60% 57% 54%

50%

40% 38% 36%

30% 28%

20% 17%

10%

0% PN ADN BSN BSRN MSN Doctorate

Source: National League for nursing. 2013. Annual Survey of School of Nursing, Fall 2012. www.nln.org/research/slides/index.htm. Data from National League for Nursing (2012). Lack of Faculty is Main Obstacle to Expanding Capacity, 2012.

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recognized, and expanded through master’s the Doctor of Nursing Practice as the entry- and doctoral education, post-master’s cer- level degree for advanced practice nursing, stat- tificate programs, continuing professional ing the following: development courses, mentoring activities, Advanced competencies for increasingly and professional certification as a faculty complex clinical, faculty and leadership roles member. Each academic unit in nursing must . . . enhanced knowledge to improve nursing include a cadre of experts in nursing educa- practice and patient outcomes . . . enhanced tion who provide the leadership needed to leadership skills . . . better match of program requirements . . . provision of an advanced advance nursing education, conduct peda- educational credential . . . parity with other gogical research, and contribute to the ongo- health care professionals . . . enhanced ability ing development of the science of nursing to attract individuals to nursing from non- education. nursing backgrounds; increased supply of faculty for clinical instruction; and improved Nurse Practitioners image of nursing. (AACN, 2004, p.7) Nurse practitioners have been providing care Today, nurse practitioners are the largest to vulnerable populations in rural and urban group of advanced practice nurses. More than areas since the 1960s. The role was born out of 192,000 NPs are licensed and practicing with the shortage of primary care physicians able to some level of prescriptive authority in all 50 serve pediatric populations. Initial educational states and the District of Columbia (Ameri- preparation ranged from 3 to 12 months, and can Association of Nurse Practitioners, 2013). as the role developed and expanded so did Nurse practitioners work, are educated, and educational requirements. By the 1990s, the hold board certification in a variety of specialty master’s degree was endorsed as entry-level areas, including pediatrics, family, adult-geron- education for nurse practitioner specialties. In tology, women’s health, and acute care, to name 2004, the AACN took a position recognizing a few. (See Table 1-3.)

Table 1-3 Distribution, Mean Years of Practice, Mean Age by Population Focus

Population Percentage of NPs Years of Practice Age (years) Acute care 6.3 7.7 46 Adult* 18.9 11.6 50 Family* 48.9 12.8 49 Gerontological* 3.0 11.6 53 Neonatal 2.1 12.2 49 Oncology 1.0 7.7 48 Pediatric* 8.3 12.4 49 Psych/mental health 3.2 9.1 54 Women’s health* 8.1 15.5 53 *Primary care Source: Data from the 2010 AANP National Practice Site Survey.

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A federal initiative continues to exist to births, and maternal and infant outcome statis- increase the number of primary care providers tics in rural Kentucky were better than those for in the United States. The 2010 consensus report the whole country during the nurse-midwives entitled the Future of Nursing developed by the first three decades of service. The most sig- Institute of Medicine (IOM) and the Robert Wood nificant differences were in maternal mortality Johnson Foundation (RWJF) calls for a transfor- rates (9.1 per 10,000 births for FNS compared mative change in nursing education. It calls for with 34 per 10,000 births for the United States nurses to “practice to the full extent of their edu- as a whole) and low birth weights (3.8% for FNS cation and training” and for “nurses to achieve compared with 7.6% for the country). higher levels of education and training through Today, all nurse-midwifery programs are an improved education system” (Institute of housed in colleges and universities. There are Medicine, 2010). This analysis and recommenda- multiple entry paths to midwifery education, tion coincided with the passage of the legisla- but most nurse-midwives graduate at the mas- tion for the Patient Protection and Affordable ter’s degree level and several programs culmi- Care Act (2010), which is estimated to increase nate in the DNP degree. These programs must the need for qualified primary care providers to be accredited by the American College of Nurse- 241,200 by 2020. The supply of primary care NPs Midwives (ACNM) for graduates to be eligible is projected to increase by 30%, from 55,400 in to take the national certification examination 2010 to 72,100 in 2020 (Health Resources and offered by the American Midwifery Certifica- Services Administration, Bureau of Health Pro- tion Board (AMCB). Midwifery practice as con- fessions, National Center for Health Workforce ducted by certified nurse-midwives (CNMs) and Analysis, 2013). This coupled with a demograph- certified midwives (CMs) is the autonomous ically aging and ethnically diverse population primary care management of women’s health, makes the demand for primary care providers, in focusing on pregnancy, childbirth, the postpar- particular, nurse practitioners, greater than ever. tum period, care of the newborn, family plan- It is well known that nurse practitioners provide ning, and gynecologic needs of women. high-quality, safe, and cost-effective care. Excel- CNMs are licensed, independent healthcare lent educational programs are needed to increase providers who have prescriptive authority in this pool of healthcare providers to improve all 50 states, the District of Columbia, Ameri- access to care and strengthen care provided for can Samoa, Guam, and Puerto Rico. CNMs are elderly and other vulnerable populations. defined as primary care providers under federal law. Although midwives are well known for Nurse-Midwives attending births, 53.3% of CNMs identify repro- The first nurse-midwifery school was estab- ductive care and 33.1% identify primary care lished in 1925 by Mary Breckenridge, who as their main responsibilities in their full-time founded the Frontier Nursing Service (FNS) positions (Fullerton, Schuiling, & Sipe, 2010). in Hyden, Kentucky, in response to the high Examples include performing annual exams; maternal and child death rates in rural east- writing prescriptions; providing basic nutrition ern Kentucky, an area isolated by geography counseling, parenting education, and patient and poverty. The midwives were educated to education; and conducting reproductive health provide family health services, as well as child- visits. According to the American Midwifery bearing and delivery care, at nursing centers Certification Board, there are 13,071 CNMs and in the Appalachian Mountains. As reported 84 CMs in practice in the United States. Since by the FNS (2014), by the late 1950s the FNS 1991, the number of midwife-attended births nurse-midwives had attended more than 10,000 in the United States has nearly doubled. In

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2012, CNMs or CMs attended 313,846 births— Medicaid reimbursement for midwifery care is a slight increase despite a decrease in total U.S. mandatory in all states and is 100% of the phy- births compared with births in 2011. sician fee schedule under the Medicare Part B In 2012, CNMs or CMs attended 91.7% of fee schedule. The majority of states also man- all midwife-attended births, 11.8% of all vagi- dates private insurance reimbursement for mid- nal births, and 7.9% of total U.S. births (Martin, wifery services. It is clear that nurse-midwives Hamilton, Osterman, Curtin, & Mathews, 2013). have improved primary healthcare services for Figure 1-3 shows birth data from 2000 to 2012. women in rural and inner-city areas. It is impera- Whereas the majority of midwife-attended births tive that nurse-midwives be given a larger role in occurs in hospitals, some occur at home and in delivering women’s health care for the greater freestanding birth centers. See Figure 1-4. good of society. Allowing CNMs to have hospital privileges as full, active members of the medical staff Nurse Anesthetists would promote continuity of care, and birth According to the American Association of certificate data would more accurately reflect Nurse Anesthetists (AANA), nurses have been provider type and outcomes (Buppert, 2012). providing anesthesia services to patients in the

Percentage of births attended by certified nurse-midwives and Figure 1-3 certified midwives, 2002–2012.

FPO

Martin, J., Hamilton, B., Osterman, M., Curtin, S., & Mathews, T. (2013). Births: Final data for 2012. National Vital Statistics Reports, 62(9). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr62 /nvsr62_09.pdf

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Site of births attended by certified nurse-midwives and certified Figure 1-4 midwives, 2012.

FPO

United States for more than 150 years. The (2013), the states with the highest employment first anesthesia administered to patients was level for CRNAs are Texas, Tennessee, North chloroform used for the treatment of wounded Carolina, Florida, and Ohio. soldiers during the American Civil War. The The credential CRNA came into existence in shortages of physicians qualified to administer 1952 when the AANA established an accredita- anesthesia during wartimes continued, and tion program to monitor the quality and consis- nurse anesthetists were the main providers of tency of nurse anesthetist education (Keeling, anesthesia care for U.S. military personnel on 2009). Today, CRNAs safely administer anes- the front lines for World War I, World War II, thetics in more than 34 million cases each year the Korean War, and the Vietnam War; nurse in the United States, according to the American anesthetists also provide care in the current Association of Nurse Anesthetists (AANA) 2012 conflicts in the Middle East (Keeling, 2009). Practice Profile Survey. There are more than Historically, nurse anesthetists have been 44,000 CRNAs practicing in the United States the primary providers of anesthesia care in rural (AANA, 2011). The scope and standards of prac- America, enabling healthcare facilities in medi- tice for CRNAs are similar to those for other cally underserved areas to offer obstetrical, advanced practice registered nurses. Nurse surgical, pain management, and trauma stabi- anesthetists are licensed as independent prac- lization services. In some states, CRNAs are the titioners, and they provide care autonomously sole providers in nearly 100% of rural hospitals. and in collaboration with surgeons, dentists, According to the U.S. Bureau of Labor Statistics podiatrists, and anesthesiologists, among other

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healthcare professionals. CRNAs provide evi- in nursing baccalaureate programs, let alone dence-based anesthesia and pain care services associate degree/diploma programs, yet some to patients at all acuity levels in a variety of set- of these exams are offered to experienced nurse tings for procedures, including, but not limited managers without a baccalaureate and/or mas- to, surgical, obstetrical, diagnostic, therapeu- ter’s degree as noted in Table 1-4. tic, and pain management (AANA, 2013). Cur- There are two organizations that certify nurse rently, CRNAs are qualified and have the legal administrators: the American Nurses Creden- authority to administer anesthesia without tialing Center and the American Organization of anesthesiologist supervision in all 50 states, the Nurse Executives. Both offer certification exams District of Columbia, Puerto Rico, and the Vir- in basic and advanced nursing administration. gin Islands; however, some states have put into Table 1-4 includes the educational requirement place restrictions and supervisory requirements for each organization. Years and levels of experi- in some settings (Joel, 2013). ence vary for each certification exam and can be accessed on their websites (American Nurses Nurse Administrators Credentialing Center, 2014; American Organi- zation of Nurse Executives, 2014). The term nurse administrators is being used to Further complicating the preparation of simplify the below discussion. This includes nurse administrators are the practices of many roles such as the nurse executive, supervisor, organizations of: director, nurse manager, and so forth. Since individuals in these roles are responsible for ■■ Promoting good “bedside’ nurses to mana- leading a successful work environment, it is gerial positions without assessing or devel- ironic that educational requirements for nurse oping their leadership abilities administrators are not as demanding as those ■■ Weak orientation/on-the-job training for for other advanced practice roles. The knowl- new nurse administrators edge, skills, and attitudes needed to be success- ■■ No requirements for an advanced degree for ful as a nurse administrator are not included the position

Educational Requirements for Nurse Administrator Certifying Table 1-4 Organizations

American Nurses Credentialing Center American Organization of Nurse Executives Basic certification Hold a bachelor’s or higher degree in Associate degree nursing Diploma Bachelor’s degree Advanced certification Hold a master’s or higher degree in nursing, Master’s degree or higher or hold a bachelor’s degree in nursing and a master’s in another field Source: Data from American Nurses Credentialing Center (ANCC). (2014). ANCC certification center. Retrieved from http://www.nursecredentialing.org/Certification; American Organization of Nurse Executives (AONE). (2014). About AONE credentialing center. Retrieved from http://www.aone.org/resources/certification/about_cer- tifications.shtml

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Conclusion American Association of Colleges of Nursing (AACN). (2007). White paper on the role of the clinical nurse A national initiative exists to improve access to leader. Retrieved from http://www.aacn.nche.edu/ quality health care while reducing costs. This aacn-publications/white-papers/cnl-white-paper mandate will require the emergence of many American Association of Colleges of Nursing (AACN). new roles, not yet imagined for nurses. Recently, (2011a). The essentials of master’s education in nursing. new roles to serve as coordinators of care, such Washington, DC: Author. as nurse navigators and healthcare coaches, American Association of Colleges of Nursing have been established. In the future, these roles (AACN). (2011b). 2010–2011 enrollment and gradu- ations in baccalaureate and graduate programs in nurs- may require advanced degrees and certification. ing. Washington, DC: Author. Opportunities for nurses to coordinate care American Association of Colleges of Nursing throughout the continuum of care are likely (AACN). (2014). Essentials series. Retrieved from to abound. The aging population will require http://www.aacn.nche.edu/education-resources nurses to be “chronic disease specialists” and /essential-series “wellness coaches.” Population health, gender- American Association of Nurse Anesthetists (AANA). specific health care, and global health special- (2011). CRNAs and the AANA fact sheet for patients. Retrieved from http://www.aana.com/forpa- ties will become the norm. An understanding tients/Documents/crnas_aana.pdf of the healthcare delivery system, healthcare American Association of Nurse Anesthetists (AANA). policy, and care transition will need to be incor- (2013). Professional practice documents: scope of nurse porated into graduate curricula. As this book anesthesia practice. Retrieved from http://www goes to press, there is a push to expand and .aana.com/resources2/professionalpractice clarify the definition of and requirements for /Pages/Scope-of-Nurse-Anesthesia-Practice.aspx advanced practice nursing. No matter the final American Association of Nurse Practitioners (AANP). (2013). NP fact sheet. Retrieved from http://www outcome of this deliberation, all nurses need .aanp.org/all-about-nps/np-fact-sheet the same set of essential knowledge and the American College of Nurse-Midwives (ACNM). Author: This ability to think outside the box. (2014). Fact sheet: Essential facts about midwives. source is not Retrieved from http://www.midwife.org/ACNM cited in this Discussion Questions /files/ccLibraryFiles/FILENAME/000000004001 chapter. Do you /EssentialFactsAboutMidwives-2014_FINAL.pdf wish to retain 1. What are the differences between the terms American Nurses Credentialing Center (ANCC). it in the Refer- advanced practice nursing and advanced practice (2014). ANCC certification center. Retrieved from ences list or to registered nurse? http://www.nursecredentialing.org/Certification delete it? American Organization of Nurse Executives (AONE). 2. What emerging roles should be considered (2014). About AONE credentialing center. when describing advanced practice nursing? Retrieved from http://www.aone.org/resources 3. Why was the APRN Consensus Model devel- /certification/about_certifications.shtml oped and what does it hope to do for the APRN Consensus Work Group & National Council provision of health care? of State Boards of Nursing APRN Advisory Committee. (2008, July 7). Consensus model for APRN regulation: Licensure, accreditation, References certification and education. APRN Joint Dialogue American Association of Colleges of Nursing (AACN). Group Report. Retrieved from http://www.aacn (2004). AACN position statement on the practice doc- .nche.edu/education-resources/APRNReport torate in nursing. Retrieved from http://www.aacn .pdf .nche.edu/DNP/pdf/DNP.pdf Buppert, C. (2012). Hospital privileges. In C. Bup- American Association of Colleges of Nursing (AACN). pert (Ed.), Nurse practitioner’s business practice and (2006). The essentials of doctoral education for advanced legal guide (pp. 247–253). Burlington, MA: Jones & nursing practice. Washington, DC: Author. Bartlett Learning.

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Frontier Nursing Service. (2014). A brief history of Keeling, A.W. (2009). A brief history of advance nurs- the Frontier Nursing Service. Retrieved from ing practice in the United States. In A. B. Ham- https://www.frontiernursing.org/History/HowF- ric, J. A. Spross, & C. M. Hanson (Eds.), Advanced NSbegan.shtm practice nursing: An integrative approach (4th ed., Fullerton, J., Schuiling, K., & Sipe, T. A. (2010). Find- pp. 3–32). St. Louis, MO: Elsevier. ings from the analysis of the American College Martin, J., Hamilton, B., Osterman, M., Curtin, S., & of Nurse-Midwives’ membership surveys: 2006– Mathews, T. (2013). Births: Final data for 2012. 2008. Journal of Midwifery and Women’s Health, 55, National Vital Statistics Reports, 62(9). Retrieved 299–307. from http://www.cdc.gov/nchs/data/nvsr Fulton, J. S. (2014). Evolution of the clinical nurse /nvsr62/nvsr62_09.pdf specialist role and practice in the United States. McClelland, M., McCoy, M., & Burson, R. (2013). Clini- In J. S. Fulton, B. L. Lyon, K. A. Goudreau (Eds.), cal nurse specialists: Then, now, and the future of Foundations of clinical nurse specialist practice (2nd the profession. Clinical Nurse Specialist, 27(2), 96–102. ed., pp. 1–16). New York, NY: Springer. National Association of Clinical Nurse Specialists. Haase-Herrick, K., & Herrin, D. (2007). The American (2005). Statement on clinical nurse specialist practice organization of nurse executives’ guiding prin- and education (2nd ed.). Harrisburg, PA: Author. ciples and American Association of Colleges of National CNS Competency Task Force. (2010). Nursing’s clinical nurse leader. Journal of Nursing Clinical nurse specialists core competencies: Executive Administration, 37(2), 55–60. summary 2006–2008. Retrieved from http://www Health Resources and Services Administration, .nacns.org/docs/CNSCoreCompetenciesBroch. Bureau of Health Professions, National Center pdf for Health Workforce Analysis. (2013). Projecting National League for Nursing (NLN). (2002). Position. the supply and demand for primary care practitioners Retrieved from http://www.nln.org/aboutnln through 2020. Retrieved from http://bhpr.hrsa /PositionSTatements/prepofnursed02.htm .gov/healthworkforce/supplydemand/uswork- National League for Nursing (NLN). (2012). Annual force/primarycare/projectingprimarycare.pdf Surveys of Schools of Nursing. Fall 2011. Retrieved Institute of Medicine. (2010). The future of nursing: from http://www.nln.org/researchgrants/slides Leading change, advancing health. Retrieved from /topic_admissions_rn.htm http://www.iom.edu/Reports/2010/the-future- U.S. Bureau of Labor Statistics. (2013). Occupational of-nursing-leading-change-advancing-health.aspx employment and wages 29-1151 nurse anesthetists. Joel, L. (2013). Advance practice nursing: Essentials of role Retrieved from http://www.bls.gov/oes/current development (3rd ed.). Philadelphia, PA: F. A. Davis. /oes291151.htm#stTable 1-1

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