Current Events Impacting APRN Practice

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Current Events Impacting APRN Practice

• Janet Selway DNSc CRNP
• Assistant Professor
• University of Delaware
• School of Nursing
• jselway_at_udel.edu

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Topics for Today

• APRN Consensus Model for Future Regulation
• NP DNP Education, Certification and Titling A
  Unified Statement
• Medical Home Demonstration Project
• ACP Position Paper on NPs in Primary Care

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Current APRN Regulation

• Each state independently determines
• APRN legal scope of practice
• Roles that are recognized
• Criteria for entry level
• Certification exams accepted

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Current APRN Regulation

• The problem No uniform APN regulation model
  across states in the context of expanded numbers
  and capabilities of APNs.

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The APRN Consensus Model

• Future Model for Regulation of APRNs
• Vision Paper completed July 2008 after 4 years
• Recommended by the National Council State Boards
  of Nursing to be implemented in every state by
  2015
• The entire APRN Consensus Model document and
  accompanying model legislative language can be
  found at www.ncsbn.org

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APRN Stakeholders

• NCSBN APRN Committee
• APRN Consensus Workgroup
• APRN Joint Dialogue Group
• 23 organizations representing education,
  accreditation, certification, practice and
  regulation
• Individual Boards of Nursing
• Stakeholder Professional Organizations

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What does the APRN Consensus Model do?

• Defines APRN practice
• Describes the regulatory model
• Identifies title to be used
• Defines specialty
• Describes emergence of new roles and population
  foci
• Describes strategies for implementation

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Definition of APRN Practice(7 Points)

• 1. Competed accredited graduate program prepared
  for one of the 4 roles
• 2. National certification/re-certification
• 3. Advanced knowledge/skills in direct care
• 4. Practice builds on RN competencies

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Definition of APRN Practice

• 5. Educationally prepared to assume
  responsibility and accountability for health
  promotion and/or maintenance as well as the
  assessment, diagnosis, and management of patient
  problems, which includes the use and prescription
  of pharmacologic and non-pharmacologic
  interventions
• 6. Clinical experience of sufficient depth and
  breadth to reflect the intended license
• 7. Licensed to practice in one of the 4 APRN
  roles

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Describes APRN Regulatory Model Definition of
APRN Roles

• Rationale Not all advanced graduate nursing
  roles focus on direct patient care, and so do not
  require regulation beyond the RN role.
• Four nursing roles to be recognized as APRN
• Certified Nurse Midwife
• Certified Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist

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Describes APRN Regulatory Model Role --gt
Population Foci

• An APRN must be educated in one of the 4 roles
  and
• At least one population foci
• Family/individual across the lifespan
• Adult-gerontology
• Pediatrics
• Neonatal
• Womens health/gender-related
• Psych/mental health
• Education, Certification, Licensure must be
  congruent in terms of role and population foci

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Describes APRN Regulatory Model APRN Education

• All APRN education programs must be accredited
  (degree-granting and post masters)
• Housed within nationally accredited graduate
  programs
• Graduates must be eligible for national
  certification
• Broad-based education 3 grad-level courses
• Pathophysiology/physiology
• Health Assessment
• Pharmacology

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Describes APRN Regulatory Model APRN Licensure

• Individuals will be licensed as independent
  practitioners at the level of role and population
  foci
• No licensure at the specialty level

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Defines APRN Titling

• The title Advanced Practice Registered Nurse
  (APRN) is the licensing title to be used for the
  subset of nurses prepared with advanced,
  graduate-level nursing knowledge to provide
  direct patient care in four role
• APRN is a legally protected title based on
  education and scope of practice within one of the
  4 roles and 6 population foci.

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Describes APRN Regulatory Model Role --gt
Population Foci--gt Specialty

• No licensure solely within a specialty area
• Competence at the specialty level will not be
  assessed or regulated by BONs but rather by
  professional organizations
• Education and assessment strategies for specialty
  areas will be developed by the nursing profession
  (Nursing Organizations and SIGs)

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Describes emerging new roles or population foci

• A new role or population focus should be
  discussed and vetted through the national
  Licensure, Accreditation, Certification,
  Education communication structure LACE.
• Describes 8 characteristics for the process of
  developing a new APRN role or population foci and
  criteria for recognition

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Describes strategies for implementation

• LACE a formal ongoing communication mechanism
  that provides for transparent and aligned
  communication among those entities that represent
  Licensure, Accreditation, Certification and
  Education

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Describes strategies for implementation

• Key points Licensure
• BONS will be solely responsible for licensure of
  APRNs
• License APRNs as independent practitioners with
  no regulatory requirements for collaboration,
  direction or supervision
• APRN representative on BONs
• APRN Compact
• Provides for grandfathering

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Describes strategies for implementation

• Key points Accreditation
• Accreditors will evaluate degree granting and
  post masters program
• Accreditors will have an APRN on the visiting team

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Describes strategies for implementation

• Key points Certification
• Certification Programs will
• Assess specialty competencies, if appropriate,
  separately from the APRN core, role and
  population-focused competencies
• Enforce congruence (role and population focus)
  between the education program and the type of
  certification examination

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Describes strategies for implementation

• Key pointsEducation
• Follow the educational standards, ensure
  attainment of the APRN core, role core and
  population core competencies
• Be accredited (USDE, CHEA)
• Be pre-approved, pre-accredited or accredited
  before accepting students
• Ensure that grads will be state/national
  certification-eligible
• Ensure that transcript specifies the role and
  population foci

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Current Status of APRN Regulatory Model

• Now being considered by stakeholders for
  endorsement
• Endorsing organizations so far
• American Nurses Association
• National Council of State Boards of Nursing
• American Association of Colleges of Nursing
• National Organization of NP Faculty
• National Certification Corporation
• Wound, Ostomy and Continence Nurses Society
• Emergency Nurses Association

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NP DNP Education, Certification and Titling A
Unified Statement

• Statement endorsed by 7 organizations
  representing nurse practitioners
• Citation
• Nurse Practitioner Roundtable (June, 2008).
  Nurse Practitioner DNP Education, Certification
  and Titling A Unified Statement. Washington,
  DC Author
• The Nurse Practitioner Roundtable is a coalition
  of nurse practitioner organizations formed to
  collaborate, unify, and address issues of
  importance to nurse practitioners. The Nurse
  Practitioner Roundtable is currently composed of
  the organizations listed above.
• Stimulus for this was the April 2, 2008 Wall
  Street Journal article entitled Making Room for
  Dr. Nurse by Laura Landry

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NP DNP Education, Certification and Titling A
Unified Statement

• To establish a national standard for doctors of
  nursing practice, the non-profit Council for the
  Advancement of Comprehensive Care plans to
  announce Wednesday that the National Board of
  Medical Examiners has agreed to develop a
  voluntary DNP certification exam based on the
  same test physicians take to qualify for a
  medical license.
• --- Landry L. The informed patient Making
  room for Dr. Nurse. WSJ. April 2, 2008. p. D-1.

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NP DNP Education, Certification and Titling A
Unified Statement

• In addition to training in diagnostic and
  treatment skills, doctors of nursing practice can
  have hospital admitting privileges, coordinate
  care among specialists, help patients with
  preventive care, evaluate their social and family
  situations, and manage complex illnesses such as
  diabetes and heart disease, says Dr. Mundinger,
  who has been leading the effort behind the
  National Board of Medical Examiners' planned
  certification exam.
• --Landry L. The informed patient Making room
  for Dr. Nurse. WSJ. April 2, 2008. p. D-1.

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NP DNP Education, Certification and Titling A
Unified Statement

• A joint statement in response to information in
  the Landry article
• Endorsed by
• AANP
• ACNP
• AFPNP
• NAPNAP
• NCGNP
• NONPF
• NPWH

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NP DNP Education, Certification and Titling A
Unified Statement

• Key points
• Presents an accurate description of masters and
  DNP NP education, and NP certification
• NP certification exams are based on role
  delineation studies and are psychometrically
  sound, and that current NP certification exams
  will evolve as needed
• Certification exams test competencies of a role
  and not of a degree
• The transition from the masters to doctoral
  preparation for NP practice does not require
  additional testing beyond nurse practitioner
  certification to measure competency to practice.

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NP DNP Education, Certification and Titling A
Unified Statement

• Key points
• Addressed the issue of doctorally prepared NPs
  using the title of Dr. in the clinical setting
• Dr. is an academic credential not owned by any
  one discipline
• Dr. is not limited to medical doctors
• Medical Doctor and Doctor of Osteopathy are
  title protected, but doctor is not.
• Recognition of the title, Doctor for doctorally
  prepared nurse practitioners facilitates parity
  within the health care system

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Medical Home Demonstration Project

• The issue Includes MDs and DOs only, NPs can
  participate but only as part of a practice
• The Medicare Improvement for Patients and
  Providers Act of 2008 (Public Law (P.L.)
  110-275), more commonly referred to as The
  Medicare bill became law on July 15, 2008
• Contains an expansion of the Medicare medical
  home demonstration project created by the earlier
  Medicare Improvement and Extension Act of 2006
  (P.L. 109-432) 

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Medical Home

• Came about because of
• Lack of access for uninsured
• Increased health care costs
• Impending collapse of primary care
• No link between cost and quality
• ACP- White Paper 2006

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Medical Home Demonstration Project

• Purpose is to test the idea of providing Medicare
  beneficiaries with a medical home and to give
  physicians a bonus payment for such services 
• The Secretary of Health and Human Services has
  authority to expand the project
• 4 US Senators inserted a colloquy (formal
  dialogue) into the Congressional Record
  supporting NPs to be included in Medical
  Demonstration Projects.

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Medical Home

• Health care as it should be
• A place for patients to go for comprehensive
  coordinated care
• Model should be tested to determine benefit

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Medical Home Demonstration Project-

• Senatorial Colloquy
• Senator Bingaman (D-NM)
• Senator Harkin (D-IA)
• Senator Collins (R-ME)
• Senator Murkowski (R-AK) 
• Congressional Record, July 9, 2008 S6845

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Medical Home Policy Implications

• Assumes physicians are the best provider for
  primary care
• Ignores abilities of NPs to lead medical homes
• Does not provide for data collection on NP care

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Medical Home

• Patient Centered Primary Care Collaborative
• Coalition of major employers, consumer groups,
  patient quality organizations, health plans,
  labor unions, hospitals, physicians and many
  others
• Purpose is to develop and advance the patient
  centered medical home.

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Patient-Centered Primary Care Collaborative
(PCPCC)

• Over 300 members
• Founding principles do not contain provider
  neutral language
• 3-26-09 Update Founding principles are now
  attributed to AAFP, ACP, AAP, AOA as opposed to
  the entire PCPCC
• ACNP and NONPF joined the PCPCC)
• Goal
• Improve provider-patient relationships
• Create a more efficient and effective health care
  delivery model

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ACP Position Paper on NPs in Primary Care

• Resulted from productive meetings with NP leaders
  April July 2008
• Contains some physician centric statements
• Acknowledges the vital role NPs play in primary
  care
• Advocates for research to develop effective
  consultation between MDs NPs
• Supports NP led PCMH projects
• Collaboration defined as interdisciplinary

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Websites of Interest

• APRN Consensus Model
• https//www.ncsbn.org/7_23_08_Consensue_APRN_Final
  .pdf
• Chart Overview of NP Scopes of Practice in the US
• http//www.acnpweb.org/i4a/pages/index.cfm?pageid
  3465

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Websites of Interest

• AACN Essentials of Doctoral Education for
  Advanced Nursing Practice
• http//www.aacn.nche.edu/DNP/pdf/Essentials.pdf
• NP Roundtable Unified Statement re DNP CACC
  Exam
• http//www.acnpweb.org/files/public/DNP_GROUP_LETT
  ER_6-08_w_copyright.pdf
• AACN the CACC Exam for DNP
• http//www.aacn.nche.edu/dnp/pdf/CCExamStatement.p
  df

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Websites of Interest

• Medical Home Patient-Centered Primary Care
  Collaborative
• www.pcpcc.net
• American College of Physicians Position Paper on
  NPs in Primary Care
• http//www.acponline.org/advocacy/where_we_stand/p
  olicy/np_pc.pdf