Advanced Practice Nursing

1
Advanced Practice Nursing

• Difference between NPs and PAs
• Barriers to APNs

2
The Origin of NPs and PAs

• Gaps in the distribution of physicians and
  services in the rural and inner city .
• The cost effectiveness of these two roles,
  especially when the health care cost is rising.
• The patients high satisfaction level with NPs
  and PAs
• In 2006, NPs and PAs have accounted for around
  one sixth of medical workforce in United States.

3
NPs vs PAs Scope of Practice

• The supervisory physician is responsible for the
  PA at all times and must be available for
  consultation
• A nurse practitioner works either independently
  or as part of a health care team

4
NPs vs PAs Education

• All Pas and NPs are now graduates of formal,
  accredited education programs. Most are at the
  graduate level, providing a masters degree as a
  standard of education for both NPs and PAs.
• The education of PAs students is disease
  centered, while for NPs students, it also
  emphasizes psychological and social care.
• The NP curriculum follows nursing models of
  practice and emphasizes health assessment,
  diagnosis, and treatment, as well as health care
  maintenance and disease prevention.

5
NPs vs PAs Abilities and Limitations

• 12 states nurse practitioners have no
  collaboration requirement, 4 states require
  physician involvement but no written
  documentation.
• 11 states and D.C allow for nurse practitioners
  for independent prescriptive authority
• PAs now are licensed in 44 states, but they have
  to work under the authority of a physician.

6
Comparison of NPs and PAs (Table from Curren,
2007)
7
The barriers to APNs Public Policy

• The ability to be credentialed by health care
  organizations is very important for APNs to have
  their own patients, but this credentialing is
  very difficult in managed care organizations
  (MCOs)
• In many states of United States, physician
  involvement is required for APN prescription
  authority.

8
The barriers to APNs Role Change

• Conflict arose when APNs found that the practice
  setting did not allow them to practice in a
  holistic manner that was consistent with the
  nursing role.
• Teaching and counseling is an important part of
  the APN role and couldnt be ignored
• APNs are not physician substitutes, they should
  offer added difference

9
Conclusion

• Compared with PAs, NPs have more privileges
• No need to work under the authority of a
  physician
• Prescription Authority
• There are still barriers to APNs
• Limitations on the credentialing and prescription
• Sometimes hard to be consistent with the nursing
  role.
• We should be ready to embrace the challenges
• Strong demand for APNs because of cost
  effectiveness and high satisfaction level
• The constraints to the practice of APNs are
  gradually removed by legislation.

10
The CNS as an Advance Practice Nurse

• Why Washington State Needs Change

11
What is an Advance Practice Nurse?

• Advanced Practice Registered Nurse (APRN) is an
  umbrella term for four groups of advanced
  practice nurses.
• Clinical Nurse Specialists
• Nurse Anesthetists
• Nurse Midwives
• Nurse Practitioners
• All with a Different Focus and Scope of Practice

12
What is a CNS?

• The first APRN
• unique body of knowledge and competencies based
  on education at the graduate level (Mick and
  Ackerman, 2002)
• Advance Practice Nursing Started with Peplau in
  the 1940s (Peplau, 1965).
• Differentiated from the expertise of other APRN
• In 1965 the ANA declare that the that the Title
  of CNS should only be used by Nurses with a
  Masters Degree and higher (ANA, 1965)

13
CNS Scope and Expertise

• Three Main Spheres of Influence
• Patient/client sphere
• Nurse/Nursing Sphere and
• System/Organizational Sphere (NACNS, 2004).
• Specialized Knowledge, Experience, and Education
  in a specific field, setting, or population.
• Prescriptitory rights in field of specialization.
• Varies by State

14

• FNP

• CNS

• Specific Patient Population
• Specific Scope
• Acute Care
• System wide Focus
• Researcher
• Staff Educator
• Focus on Quality of Care Issues

• Individual Patient
• General Scope
• Primary Care
• Individual Focus
• Focus on direct patient care

15
Prescriptitory authority

• Referral and consultation to other HCP
• Durable Medical Equipment
• Diagnostic Test
• Pharmacologic when appropriate to Specialty

16
Protection of Title

• Not a protected title in Washington State
• Washington Department of Personnel in July, 2007
  created a Class Specification
• Specific Distinguishing Characteristics
• Specific description of Typical Work
• Specific Knowledge and Abilities
• BUT, legal requirements are only a RN
• AND, a Masters Degree is only Desirable and
  Equivalent education / experience can
  substitute

17
Why Should the Title Be Protected with
Educational Requirements

• Improve Patient Care
• Increased Education Increases Nursing Care (AACN,
  2008)
• Provide Incentives for Educational Growth
• Some States are Offering a 20,000 signing bonus
  for CNS
• Establish Parity with other Professions
• PA, Current Pharmacist, Current PTs
• Establish Parity with other States

18
Where is the Title Protected

• Idaho-Prescriptotry Rights (PR)
• Oregon (PR)
• California
• Nebraska
• New Mexico
• Georgia (Psy/MH)(PR)
• New York
• Texas Second License (SL)
• Ohio (SL)
• Minnesota (SL)
• Arkansas (SL)
• Most Other States

19
How is it Protected

• Legislative actions
• Laws
• Nursing Practice acts
• State Nursing Board Changes
• Certification
• Registration
• Some State second Licensing
• Specific Requirements

20
Second License Concerns

• There are over 40 CNS specialty areas of practice
• Only 9 CNS specialty exams exist (NACNS, 2003)
• -Adult -Acute and Critical Care
• -Gerontology -Pediatrics
• -Adult Mental Health -Pediatric Mental Health
• -Home Health -Diabetes Management
• -Public/Community Health
• If a specialty exam does not exist may have to
  take a general med/surg exam.

21
A New Way

• ANCC New Core CNS Clinical Nurse Specialist Exam
  (currently under Development)
• Critical Portfolio
• Examine Experience and Education
• Use of other exams
• Oncology Certified Nurse
• Certified Nurse Operating Room (CNOR)
• RN First Assist (RNFA)
• Certified Chemotherapy Nurse
• Dermatology Nurse Certified (DNC)

22
Summary

• CNS Represent a unique role
• Different from NP
• Different from RN
• Title needs legal and regulatory protection
• Washington State should implement laws and
  regulations to protect and recognize the CNS role.

23
References

• Curren, J. (2007). Professional Issue. Nurse
  Practitioners and Physician Assistants Do You
  Know the Difference? MEDSURG Nursing, 2007 Dec
  16 (6) 404-7.
• Plager, KA. Conger, MM. (2007). Advanced
  Practice Nursing. Internet Journal of Advanced
  Nursing Practice, 2007 9 (1).
• McCabe, S. Burman, ME. (2006). A Tale of Two
  APNs Addressing Blurred Practice Boundaries in
  APN Practice. Perspectives in Psychiatric Care,
  2006 Feb 42 (1) 3-12.
• Mick, D. J. and Ackermn, M. H. (2002).
  Deconstructing the myth of the advanced practice
  blended role Support for role divergence. Heart
  and Lung, 31(6), 393-398.
• American Nurses Association. (1965). Educational
  Preparation for Nurse Practitiners and Assistants
  to Nurses A Position Paper. American Nurses
  Association. 1965. New York.
• Peplau, H. (1965) Specialization in Professional
  Nursing. Nursing Science, 3, 268-287.
• NACNS. (2004). Statement on Clinical Nurse
  Specialist Practice and Education Second
  Edition. National Association of Clinical Nurse
  Specialist. 2004 Harrisburg, PA.
• NACNS. 2003 Testimony to the Federal Trade
  Commission on Regulatory Credentialing Barriers
  For Clinical Nurse Specialists (CNS). National
  Association of Clinical Nurse Specialist. 2004
  Harrisburg, PA. http//www.nacns.org/TESTIMONY.pdf
  . Accessed 7/26/2008.
• AACN. (2008)Fact SheetThe Impact of Education on
  Nursing Practice American Association of Colleges
  of Nursing http//www.aacn.nche.edu/Media/pdf/EdIm
  pact.pdf . Updated 6/2/08. Accessed 7/26/08