Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings: A Primer for Clinicians, Executives, and Preceptors

Abstract

Advanced practice registered nurses (APRNs), including certified nurse practitioners (CNPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs), represent a growing segment of health care professionals who provide care to patients in various settings. Although opportunities for APRNs are expanding, questions about the specific role components and scope of practice have emerged, especially because APRNs, including CNPs, are assuming greater roles in hospitals, acute and critical care, and ambulatory care settings.The term scope of practice broadly refers to the range of responsibilities that determine the boundaries within which a professional practices.1 Scope of practice is a term used by state licensing boards for various professions to define the procedures, actions, and processes that are permitted for licensed individuals on the basis of their specific education and experience and their specific demonstrated competency.2Education, certification type, licensure, and regulations defined by individual state boards of nursing also shape APRN practice. Yet, variability persists in the degree to which state board of nursing regulations promote APRN practice that is consistent with education, certification, and licensure. The Institute of Medicine’s3 report, The Future of Nursing, highlighted the importance of removing scope-of-practice barriers to promote the ability of APRNs to practice to the full extent of their education and training.In response to the need to ensure consistency in APRN education and practice, the Consensus Model for APRN Regulation emerged from a national effort to address APRN licensure, accreditation, certification, and education requirements across jurisdictions. The APRN Consensus Model proposes that the requirements for APRNs should be framed in a way that ensures the safety of patients while expanding access to APRN care and promoting a consistent scope of practice.4The national Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE), finalized in 2008, defines APRNs and standardized requirements for each of the 4 APRN regulatory components included in LACE.4 Under the Consensus Model for APRN Regulation, APRNs must be educated, certified, and licensed to practice in 1 of 4 APRN roles: CRNA, CNM, CNP, or CNS. In addition to the 4 roles, APRNs are educated and practice in at least 1 of 6 population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health and gender-related health, or psychological/mental health (Figure 1).4 Under this model, endorsed by 45 national nursing organizations, APRN practice is based on care that is defined by patient needs.The APRN Consensus Model outlines implementation issues for APRN education including clarification of education requirements for core coursework, including 3 separate graduate-level courses on advanced physiology/pathophysiology across the lifespan, advanced physical health assessment, and advanced pharmacology, sometimes referred to as the “3 Ps.”The APRN Consensus model also outlines the expectation for clinical experiences in the curriculum, highlighting the need for comprehensive experiences to prepare the graduate to practice in the APRN role and population focus. The national consensus–based competencies for each of the roles and populations delineate specific expectations, including the length of experiences, patient populations, and settings, to prepare graduates with all of the delineated competencies. Faculty expertise to prepare graduates across the entire adult-older adult spectrum and wellness-illness continuum is also addressed. Other educational components of the Consensus Model include a differentiation of acute and primary care CNP roles for the pediatric and adult-gerontology populations, inclusion of wellness in all APRN curricula, the integration of content related to care of older adults, and preparation of CNSs from wellness to acute care.4A national goal for states to implement the APRN Consensus Model is set for 2015. To achieve the 2015 full implementation target, specific projected timelines to implement components of the Consensus Model have been established and are being implemented. First, APRN education programs should be transitioned to integrate the APRN Consensus Model recommendations by 2012 to 2013. Accreditation processes should be in place by 2012 to 2013, and new certification examinations are being developed and will be in place by 2013 to 2014, while existing examinations that will no longer be specific to the Consensus Model are being retired, and current certification holders are being appropriately notified of their recertification options. The National Council of State Boards of Nursing reports that 6 states have enacted legislation during the 2012 legislation session that relates to the Consensus Model and 8 states have pending legislation (Figure 2).5As part of the APRN Consensus Model, the LACE Network was designated to ensure consistency in the education preparation, certification, and licensure requirements for APRNs. The LACE Network was developed as a communication network that includes organizations that represent the LACE components of APRN regulation.The LACE Network provides a mechanism for communicating about APRN regulatory issues, facilitating implementation of the APRN Consensus Model, and involving all stakeholders in advancing APRN regulation.6 A Web site (http://www.aprnlace.org) has been created to facilitate communication with the entire APRN community and other stakeholders.As part of the implementation of the APRN Consensus Model, updated competencies were developed to reflect the population and lifespan focus of the APRN role. National task forces were formed and the Adult-Gerontology Primary Care NP Competencies were published in 2010.7 The Adult-Gerontology CNS Competencies were published in 20108 and the Adult-Gerontology Acute Care NP Competencies9 were published in 2012. All are available in open access pdf formats on the American Association of Colleges of Nursing Web site (http://www.aacn.nche.edu/education-resources/competencies-older-adults).Specific to CNP education, certification, and practice, adult-gerontology and pediatric CNPs focus on either primary care or acute care. The adult-gerontology CNP is prepared with either the acute care or the primary care CNP competencies.A clarifying element of the APRN Consensus Model is the focus on scope of practice, which is designated on the basis of patient care needs and not on a practice setting. The APRN scope of practice is population based and should not be linked to a particular practice setting, such as a hospital or clinic setting.4,10,11 In addition, pre-APRN specialization at the RN level does not extend scope of practice at the APRN level. As an example, an RN who has intensive care unit (ICU) staff nursing experience, and possibly critical care certification, but who completes formal education and training as a primary care NP (adult-gerontology or family NP) is not prepared to practice as an acute care adult-gerontology NP.10 Although many CNPs have prior ICU experience, their education, APRN license, and certification are focused on primary care, and they would not be prepared to practice as acute care NPs. The individual would need to complete a formal acute care NP educational program (ie, a postmaster’s acute care NP certificate program) to practice as an acute care NP.10Conversely, an acute care adult or adult-gerontology NP who has staff nursing experience in the emergency department, and possibly emergency nursing certification, would not have received education and training at the APRN level to manage pediatric patients with noncomplex problems in an outpatient setting. The CNP would need to complete a formal family or pediatric NP educational program (ie, a postmaster’s family NP or a postmaster’s pediatric NP certificate program) to have a scope of practice that incorporates care of children. Table 1 outlines a decision aide that can be used to identify scope-of-practice match of patient care needs to NP education, licensure, and certification. The National Organization of Nurse Practitioner Faculties recently developed a statement on the practice of the primary care and the acute care NP practice, which further clarifies NP scope of practice.10Although the APRN Consensus Model helps clarify education, practice, and certification of APRNs, the concepts of the APRN Consensus Model urgently need to be applied to clinical practice. To apply these concepts, nurse managers and executives who hire and place APRNs, and particularly CNPs, in clinical settings must have a clear understanding of the concepts. Many factors, including uncertainty about APRN roles and scopes of practice, availability of positions, geographic availability of educational programs, and inability of APRNs to relocate to areas where positions specific to their education and preparation are available, have contributed to circumstances in which APRNs may not be in compliance with the APRN Consensus Model. This particularly applies to APRN roles in hospitals and acute care and ambulatory care settings where patient care needs have rapidly evolved and APRNs have been hired to help meet providers’ staffing deficits and improve patient access. The CNP role most commonly is affected by this type of situation. Ensuring a match between APRN education, licensure, and certification to meet patient health care needs and be congruent with scope of practice is an important consideration for clinicians, executives, and clinical preceptors who can influence APRN role development and role advancement (see Table 1).Table 2 outlines 2 clinical examples highlighting decision-making considerations. Examples pertaining to pediatric acute care practice were recently highlighted by Bolick and colleagues.12 The current health care economic climate dictates that hospitals and other facilities providing care do so in the most cost-efficient manner possible. The increasing number of elderly patients who suffer from multiple and complex diseases and the increasing number of underinsured or noninsured patients presenting for care to emergency departments and outpatient clinics force health care institutions to offer cost-effective alternatives. Regardless of the amount of clinical supervision or autonomy allowed within a practice setting, APRNs increasingly are evaluating and treating patients in all settings. Employers are seeking APRNs, especially CNPs, to either augment physician services or independently supplement or replace them because they are cost-effective in terms of lesser salary, with outcomes considered of similar or equal quality.13–17 In academic centers, integrating CNPs in multidisciplinary provider models is identified as a solution for the decreases in hospital coverage provided by physicians in training following implementation of the Accreditation Council for Graduate Medical Education duty-hour regulations.18This demand for CNP provider services in various clinical settings places the burden of appropriate selection and placement on the hiring manager. CNPs must also know their practice limitations in terms of education, certification, and the scope of practice legally authorized by their regulatory board of nursing. Sometimes the burden to fill a vacant position can outweigh making the right match of appropriate education, certification, and experience, which is especially true if the CNP has RN experience in the practice setting. Thus, hiring managers and CNPs should understand the expected outcomes of the Consensus Model to seek and to make appropriate job selections.19 The unintended consequences of working outside the regulated scope of practice could have devastating effects on both patients and practitioners. The intent of the Consensus Model is to avoid having APRNs who have been employed in positions that may not meet these expectations and who have been providing safe, high-quality care be disenfranchised. Rather, the Consensus Model sets forth a regulatory model to provide consistencies across education, accreditation, certification, and licensure that promotes APRN access and practice.Table 3 outlines several resources to promote awareness of the APRN Consensus Model, including an APRN Consensus Model toolkit, competency documents, and the LACE Network. Dissemination of these resources to administrators, educators, preceptors, and other stakeholders will help facilitate implementation of the APRN Consensus Model and help advance APRN regulation. They can also serve to provide clarity in job function and help practitioners and employers avoid negative patient outcomes, costly litigation, and possible disciplinary action based on practicing outside the approved scope of practice.Ensuring that key stakeholders are informed of the recommendations of the APRN Consensus Model remains an important component in securing APRN roles that are matched to education, licensure, and certification. Specific stakeholders such as chief nursing officers are increasingly being challenged to ensure optimal use of APRNs as well as promote supportive environments for building NP teams. Both The Joint Commission and the American Nurses Association Magnet standards, as well as some state statutes, clearly identify the chief nursing officer as responsible for nursing care delivery, even that delivered by an APRN. Clarifying APRN scope of practice and addressing controversy and confusion that continue to exist about APRN scope of practice within hospital, acute care, and ambulatory care settings will help promote the Institute of Medicine’s goals of enabling APRNs to practice to the fullest extent of their capacity and by removing barriers to practice.20Improved patient satisfaction, access, throughput, continuity of care, and physician productivity are frequently cited reasons for the expanding and evolving use of APRNs and CNPs.21 The advancement of APRN practice requires awareness of the APRN Consensus Model, including requirements for each of the LACE components as well as clarity on APRN scope of practice, to ensure that administrators, educators, preceptors, and other stakeholders are informed about key aspects, including the importance of the match of education, licensure, and certification. Support for implementation of the APRN Consensus Model at the state and national levels remains essential to ensure continued uniformity in APRN practice.