Essentials for Role Development Fourth Edition

Essentials for Role Development
Fourth Edition

Essentials for Role Development
Fourth Edition
Lucille A. Joel, EdD, APN, FAAN
Distinguished Professor
Rutgers, The State University of New Jersey
School of Nursing, New BrunswickNewark, New Jersey

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Library of Congress Cataloging-in-Publication Data
Names: Joel, Lucille A., editor.
Title: Advanced practice nursing : essentials for role development / [edited
by] Lucille A. Joel, EdD, APN, FAAN, Distinguished Professor, Rutgers, The
State University of New Jersey, School of Nursing, New Brunswick-Newark,
New Jersey.
Description: Fourth edition. | Philadelphia, PA : F.A. Davis Company, [2018]
| Includes bibliographical references and index.
Identifiers: LCCN 2017023590 | ISBN 9780803660441
Classification: LCC RT82.8 .J64 2018 | DDC 610.7306/92–dc23 LC record available at https://lccn.loc.
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The content of this text was identified only after a careful
review of the documents that shape both the advanced
practice nursing role and the educational programs
that prepare these individuals for practice. That review
allowed some decisions about topics that were essential
to all advanced practice nurses (APNs)*, whereas others
were excluded because they are traditionally introduced
during baccalaureate studies. This text is written for the
graduate-level student in advanced practice and is intended
to address the nonclinical aspects of the role.
Unit 1 explores The Evolution of Advanced Practice from
the historical perspective of each of the specialties: the
clinical nurse-midwife (CNM), nurse anesthetist (NA),
clinical nurse specialist (CNS), and nurse practitioner (NP).
This historical background moves to a contemporary focus
with the introduction of the many and varied hybrids of
these roles that have appeared over time. These dramatic
changes in practice have been a response to societal need.
Adjustment to these changes is possible only from the
kaleidoscopic view that theory allows. Skill acquisition,
socialization, and adjustment to stress and strain are
theoretical constructs and processes that will challenge
the occupants of these roles many times over the course
of a career, but coping can be taught and learned. Our
accommodation to change is further challenged as we
realize that advanced practice is neither unique to North
America nor new on the global stage. Advanced practice
roles, although accompanied by varied educational requirements and practice opportunities, are well embedded and
highly respected in international culture. In the United
States, education for advanced practice had become well
stabilized at the masters degree level. This is no longer true.
The story of our recent transition to doctoral preparation
is laid before us with the subsequent issues this creates.
The Practice Environment, the topic of Unit 2, dramatically affects the care we give. With the addition of
medical diagnosis and prescribing to the advanced practice
repertoire, we became competitive with other disciplines,
deserving the rights of reimbursement, prescriptive authority, clinical privileges, and participation as members on
health plan panels. There is the further responsibility to
understand budgeting and material resource management,
as well as the nature of different collaborative, responding,
and reporting relationships. The APN often provides care
within a mediated role, working through other professionals, including nurses, to improve the human condition.
Competency in Advanced Practice, the topic of Unit 3,
demands an incisive mind capable of the highest order of
critical thinking. This cognitive skill becomes refined as the
subroles for practice emerge. The APN is ultimately a direct
caregiver, client advocate, teacher, consultant, researcher,
and case manager. The APNs forte is to coach individuals
and populations so that they may take control of their own
health in their own way, ideally even seeing chronic disease
as a new trajectory of wellness. The APNs clients are as
diverse as the many ethnicities of the U.S. public, and the
challenge is often to learn from them, taking care to do
no harm. The APNs therapeutic modalities go beyond
traditional Western medicine, reaching into the realm
of complementary therapies and integrative health-care
practices that have become expected by many consumers.
Any or all of these role competencies are potential areas
for conflict, needing to be understood, managed, and
resolved in the best interests of the client. Some of the
most pressing issues confronting APNs today are how to
mobilize informational technology in the service of the
client, securing visibility for their work, and thinking
*Please note that the terms advanced practice nurse (APN) and advanced
practice registered nurse (APRN) are used interchangeably in this text
according to the authors choice.

vi Preface
through publication. The chapters in this section aim to
introduce these competencies, not to provide closure on
any one topic; the art of direct care in specialty practice
is not broached.
When you have completed your course of studies, you
will have many choices to make. There are opportunities
to pursue your practice as an employee, an employer, or
an independent contractor. Each holds different rights and
responsibilities. Each demands Ethical, Legal, and Business
Acumen, which is covered in Unit 4. Each requires you
to prove the value you hold for your clients and for the
systems in which you work. Cost efficiency and therapeutic
effectiveness cannot be dismissed lightly today. The nuts and
bolts of establishing a practice are detailed, and although
these particulars apply directly to independent practice,
they can be easily extrapolated to employee status. Finally,
experts in the field discuss the legal and ethical dimensions
of practice and how they uniquely apply to the role of the
APN to ensure protection for ourselves and our clients.
This text has been carefully crafted based on over
40 years of experience in practice and teaching APNs. It
substantially includes the nonclinical knowledge necessary
to perform successfully in the APN role and raises the
issues that still have to be resolved to leave this practice
area better than we found it.
Lucille A. Joel

Patricia DiFusco, MS, NP-C, FNP-BC, AAHIVS
Nurse Practitioner
SUNY Downstate Medical Center
Brooklyn, New York
Caroline Doherty, AGACNP, AACC
Advanced Senior Lecturer
University of Pennsylvania
School of Nursing
Philadelphia, Pennsylvania
Carole Ann Drick, PhD, RN, AHN-BC
American Holistic Nurses Association
Topeka, Kansas
Lynne M. Dunphy, PhD, APRN, FNP-BC, FAAN, FAANP
Professor and Associate Dean for Practice
and Community Engagement
Florida Atlantic University
Christine E. Lynn College of Nursing
Boca Raton, Florida
Denise Fessler, RN, MSN, CMAC
Fessler and Associates
Healthcare Management Consulting, LLC
Lancaster, Pennsylvania
Eileen Flaherty, RN, MBA, MPH
Staff Specialist
Massachusetts General Hospital
Boston, Massachusetts
Cindy Aiena, MBA
Executive Director of Finance
Partners HealthCare/MGH
Boston, Massachusetts
Judith Barberio, PhD, APNC
Associate Clinical Professor
Rutgers-The State University of New Jersey
School of Nursing
New Brunswick-Newark, New Jersey
Deborah Becker, PhD, ACNP, BC, CCNS
Director, Adult Gerontology Acute Care Program
University of Pennsylvania
School of Nursing
Philadelphia, Pennsylvania
Andrea Brassard, PhD, FNP-BC, FAANP
Senior Strategic Policy Advisor
Center to Champion Nursing in America at AARP
Washington, District of Columbia
Edna Cadmus, RN, PhD, NEA-BC
Clinical Professor and Speciality Director-Nursing
Leadership Program
Executive Director NJCCN
Rutgers-The State University of New Jersey
School of Nursing
New Brunswick-Newark, New Jersey
Ann H. Cary, PhD, MPH, FN, FNAP, FAAN
Dean and Professor
University of Missouri
Kansas City, School of Nursing and Health Studies
Kansas City, Missouri

viii Contributors
Phyllis Shanley Hansell, EdD, RN, FNAP, FAAN
Seton Hall University
College of Nursing
South Orange, New Jersey
Allyssa Harris, RN, PhD, WHNP-BC
Assistant Professor
William F. Connell School of Nursing
Boston College
Boston, Massachusetts
Gladys L. Husted, RN, PhD
Professor Emeritus
Duquesne University
Pittsburgh, Pennsylvania
James H. Husted
Independent Scholar
Pittsburgh, Pennsylvania
Joseph Jennas, CRNA, MS
Program Director
Clinical Assistant Professor
SUNY Downstate Medical Center
Brooklyn, New York
Lucille A. Joel, EdD, APN, FAAN
Distinguished Professor
Rutgers-The State University of New Jersey
School of Nursing
New Brunswick-Newark
New Jersey
Dorothy A. Jones, EdD, RNC-ANP, FAAN
Professor, Boston College
Connell School of Nursing
Senior Nurse, Massachusetts General Hospital
Boston, Massachusetts
David M. Keepnews, PhD, JD, RN, NEA-BC, FAAN
Dean and Professor
Long Island University (LIU) Brooklyn
Harriet Rothkopf Heilbrunn School of Nursing
Brooklyn, New York
Jane M. Flanagan, PhD, ANP-BC
Associate Professor and Program Director
Adult Gerontology
Boston College
Connell School of Nursing
Chestnut Hill, Massachusetts
Rita Munley Gallagher, RN, PhD
Nursing and Healthcare Consultant
Washington, District of Columbia
Mary Masterson Germain, EdD, ANP-BC, FNAP,
D.S. (Hon)
Professor Emeritus
State University of New YorkDownstate
Medical Center College of Nursing
Brooklyn, New York
Kathleen M. Gialanella, JD, LLM, RN
Law Offices
Westfield, New Jersey
Associate Adjunct Professor
Teachers College, Columbia University
New York, New York
Shirley Girouard, RN, PhD, FAAN
Professor and Associate Dean
State University of New York-Downstate
Medical Center
College of Nursing
Brooklyn, New York
Antigone Grasso, MBA
Patient Care Services Management Systems
and Financial Performance
Massachusetts General Hospital
Boston, Massachusetts
Anna Green, RN, Crit Care Cert, MNP
Project Manager
Australian Red Cross Blood Service
Melbourne, Australia

Contributors ix
Beth Quatrara, DNP, RN, CMSRN, ACNS-BC
Advanced Practice NurseCNS
University of Virginia Health System
Charlottesville, Virginia
Kelly Reilly, MSN, RN, BC
Director of Nursing
Maimonides Medical Center
Brooklyn, New York
Valerie Sabol, PhD, ACNP-BC, GNP-BC, ANEF,
Professor and Division Chair
Healthcare in Adult Population
Duke University
School of Nursing
Durham, North Carolina
Mary E. Samost, RN, MSN, DNP, CENP
System Director Surgical Services
Hallmark Health System
Medford, Massachusetts
Madrean Schober, PhD, MSN, ANP, FAANP
Schober Global Healthcare Consulting International
Indianapolis, Indiana
Robert Scoloveno, PhD, RN
DirectorSimulation Laboratories
Assistant Professor
Rutgers-The State University of New Jersey
School of Nursing
Camden, New Jersey
Carrie Scotto, RN, PhD
Associate Professor
The University of Akron
College of Nursing
Akron, Ohio
Dale Shaw, RN, DNP, ACNP-BC
ACNPAcute Care Neurosurgery
University of Virginia Health System
Charlottesville, Virginia
Alice F. Kuehn, RN, PhD, BC-FNP/GNP
Associate Professor Emeritus
University of Missouri-Columbia
School of Nursing
Columbia, Missouri
Parish Nurse
St. Peter Catholic Church
Jefferson City, Missouri
Irene McEachen, RN, MSN, EdD
Associate Professor
Saint Peters University
Division of Nursing
Jersey City, New Jersey
Deborah C. Messecar, PhD, MPH, AGCNS-BC, RN
Associate Professor
Oregon Health and Science University
School of Nursing
Portland, Oregon
Patricia A. Murphy, PhD, APRN, FAAN
Associate Professor
Rutgers-The State University of New Jersey
New Jersey Medical School
Newark, New Jersey
Marilyn H. Oermann, RN, PhD, FAAN, ANEF
Thelma Ingles Professor of Nursing
Director of Evaluation and Educational Research
Duke University
School of Nursing
Durham, North Carolina
Marie-Eileen Onieal, PhD, MMHS, RN, CPNP,
Faculty, Doctor of Nursing Practice
Rocky Mountain University of Health Professions
Provo, Utah
David M. Price, MD, PhD
Founding Faculty
Center for Personalized Education of Physicians
Denver, Colorado

x Contributors
Caroline T. Torre, RN, MA, APN, FAANP
Nursing Policy Consultant
Princeton, New Jersey
Formerly, Director, Regulatory Affairs
New Jersey State Nurses Association
Trenton, New Jersey
Jan Towers, PhD, NP-C, CRNP (FNP), FAANP
Director of Health Policy
Federal Government and Professional Affairs
American Academy of Nurse Practitioners
Washington, District of Columbia
Maria L. Vezina, RN, EdD, NEA-BC
Chief Nursing Officer/Vice President, Nursing
The Mount Sinai Hospital
New York, New York
Benjamin A. Smallheer, PhD, RN, ACNP-BC,
Assistant Professor of Nursing
Duke University
School of Nursing
Durham, North Carolina
Thomas D. Smith, DNP, RN, NEA-BC, FAAN
Chief Nursing Officer
Maimonides Medical Center
Brooklyn, New York
Mary C. Smolenski, MS, EdD, FNP, FAANP
Independent Consultant
Washington, District of Columbia
Shirley A. Smoyak, RN, PhD, FAAN
Distinguished Professor
Rutgers-The State University of New Jersey
School of Nursing
New Brunswick-Newark, New Jersey
Christine A. Tanner, RN, PhD, ANEF
Professor Emerita
Oregon Health and Science University
Portland, Oregon

Sheila Grossman, PhD, APRN, FNP-BC, FAAN
Professor and Coordinator
Family Nurse Practitioner Program
Fairfield University
Fairfield, Connecticut
Elisabeth Jensen, RN, PhD
Associate Professor
School of Nursing
York University
Toronto, Ontario
Linda E. Jensen, PhD, MN, RN
Professor Graduate Nursing
Clarkson College
Omaha, Nebraska
Julie Ann Koch, DNP, RN, FNP-BC, FAANP
Assistant Dean of Graduate Nursing
DNP Program Coordinator
Valparaiso University College of Nursing & Health
Valparaiso, Indiana
Linda U. Krebs, RN, PhD, AOCN, FAAN
Associate Professor
University of Colorado
Anschutz Medical Campus, College of Nursing
Aurora, Colorado
Nancy Bittner, RN, PhD
Associate Dean
School of Nursing Science and Health Professions
Regis College
Weston, Massachusetts
Cynthia Bostick, PMHCNS-BC, PhD
California State University
Carson, California
Susan S. Fairchild, EdD, APRN
Dean, School of Nursing
Grantham University
Kansas City, Missouri
Cris Finn, RN, PhD, FNP
Assistant Professor
Regis University
Denver, Colorado
Susan C. Fox, RN, PhD, CNS-BC
Associate Professor
College of Nursing
University of New Mexico
Albuquerque, New Mexico
Eileen P. Geraci, PhD candidate, MA, ANP-BC
Professor of Nursing
Western Connecticut State University
Danbury, Connecticut

xii Reviewers
Julie Ponto, RN, PhD, ACNS-BC, AOCN
Winona State UniversityRochester
Rochester, Minnesota
Susan D. Schaffer, PhD, ARNP, FNP-BC
Chair, Department of Womens, Childrens
and Family Nursing
FNP Track Coordinator
University of Florida College of Nursing
Gainesville, Florida
Beth R. Steinfeld, DNP, WHNP-BC
Assistant Professor
SUNY Downstate Medical Center
Brooklyn, New York
Lynn Wimett, EdD, APRN-C
Regis University
Denver, Colorado
Jennifer Klimek Yingling, PhD, RN, ANP-BC,
Advanced Practice Nurse
Faxton-St. Lukes Healthcare
SUNY Institute of Technology
Utica, New York
Joy Lewis, CRNA, MSN
Interim Assistant Program Director Nurse
Lincoln Memorial University
Harrogate, Tennessee
Laurie Kennedy-Malone, PhD, GNP-BC, FAANP,
Professor of Nursing
University of North Carolina at Greensboro School
of Nursing
Greensboro, North Carolina
Susan McCrone, PhD, PMHCNS-BC
West Virginia University
Morgantown, West Virginia
Sandra Nadelson, RN, MS Ed, PhD
Associate Professor
Boise State University
Boise, Idaho
Geri B. Neuberger, RN, MN, EdD, ARNP-CS
University of Kansas School of Nursing
Kansas City, Kansas
Crystal Odle, DNAP, CRNA
Director, Assistant Professor Nurse Anesthesia
Lincoln Memorial University
Harrogate, Tennessee

This book belongs to its authors. I am proud to be one among them. Beyond that, I have been the instrument to
make these written contributions accessible to todays students and faculty. I thank each author for the products of
his or her intellect, experience, and commitment to advanced practice.

8 The Kaleidoscope of Collaborative
Practice 116
Alice F. Kuehn
9 Participation of the Advanced Practice
Nurse in Health Plans and Quality
Initiatives 143
Rita Munley Gallagher
10 Public Policy and the Advanced Practice
Registered Nurse 158
Marie-Eileen Onieal
11 Resource Management 165
Eileen Flaherty, Antigone Grasso, and Cindy Aiena
12 Mediated Roles: Working
With and Through Other People 184
Thomas D. Smith, Maria L. Vezina , Mary E. Samost,
and Kelly Reilly
Unit 3 Competency in Advanced
Practice 203
13 Evidence-Based Practice 204
Deborah C. Messecar and Christine A. Tanner
14 Advocacy and the Advanced Practice
Registered Nurse 218
Andrea Brassard
15 Case Management and Advanced Practice
Nursing 227
Denise Fessler and Irene McEachen
16 The Advanced Practice Nurse
and Research 240
Beth Quatrara and Dale Shaw
Preface v
Contributors vii
Unit 1 The Evolution of Advanced
Practice 01
1 Advanced Practice Nursing: Doing What
Has to Be Done 02
Lynne M. Dunphy
2 Emerging Roles of the Advanced
Practice Nurse 16
Deborah Becker and Caroline Doherty
3 Role Development: A Theoretical
Perspective 33
Lucille A. Joel
4 Educational Preparation of Advanced
Practice Nurses: Looking
to the Future 43
Phyllis Shanley Hansell
5 Global Perspectives on Advanced Nursing
Practice 54
Madrean Schober and Anna Green
Unit 2 The Practice Environment 91
6 Advanced Practice Nurses
and Prescriptive Authority 92
Jan Towers
7 Credentialing and Clinical Privileges
for the Advanced Practice Registered
Nurse 100
Ann H. Cary and Mary C. Smolenski

xvi Contents
25 Advanced Practice Registered Nurses:
Accomplishments, Trends, and Future
Development 387
Jane M. Flanagan, Allyssa Harris, and Dorothy A. Jones
26 Starting a Practice and Practice
Management 395
Judith Barberio
27 The Advanced Practice Nurse as Employee
or Independent Contractor: Legal and
Contractual Considerations 418
Kathleen M. Gialanella
28 The Law, the Courts, and the Advanced
Practice Registered Nurse 433
David M. Keepnews
29 Malpractice and the Advanced Practice
Nurse 445
Carolyn T. Torre
30 Ethics and the Advanced Practice
Nurse 474
Gladys L. Husted , James H. Husted , and Carrie Scotto
Index 491
Available online at
17 The Advanced Practice Nurse: Holism
and Complementary and Integrative
Health Approaches 251
Carole Ann Drick
18 Basic Skills for Teaching
and the Advanced Practice
Registered Nurse 276
Valerie Sabol , Benjamin A. Smallheer,
and Marilyn H. Oermann
19 Culture as a Variable in Practice 295
Mary Masterson Germain
20 Conflict Resolution in Advanced
Practice Nursing 328
David M. Price and Patricia A. Murphy
21 Leadership for APNs: If Not Now,
When? 336
Edna Cadmus
22 Information Technology
and the Advanced Practice Nurse 349
Robert Scoloveno
23 Writing for Publication 354
Shirley A. Smoyak
Unit 4 Ethical, Legal, and Business
Acumen 365
24 Measuring Advanced Practice Nurse
Performance: Outcome Indicators, Models
of Evaluation, and the Issue of Value 366
Shirley Girouard, Patricia DiFusco, and Joseph Jennas

The Evolution
of Advanced Practice

Advanced Practice Nursing
Doing What Has to Be Done
Lynne M. Dunphy
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Recognize the historical role of women as healers.
Identify the roots of professional nursing in the United States including the public
health movement and turn-of-the-century settlement houses.
Describe early innovative care models created by nurses in the first half of the
20th century such as the Frontier Nursing Service (FNS).
Trace the trajectory of the role of the nurse midwife across the 20th century as well
as the present status of this role.
Recognize the emergence of nurse anesthetists as highly autonomous practitioners
and their contributions to the advancement of surgical techniques and developments in anesthesia.
Describe the development of the clinical nurse specialist (CNS) role in the context
of 20th-century nursing education and professional development with particular
attention to the current challenges of this role.
Describe the historical and social forces that led to emergence of the nurse practitioner (NP) role and understand key events in the evolution of this role.
Describe the development of the doctor of nursing practice (DNP) and distinguish this role from the others described in this chapter.
Describe the current challenges to all advanced roles and formulate ways to meet
these challenges going forward.

Chapter 1 Advanced Practice Nursing 3
Advanced practice is a contemporary term that has evolved
to label an old phenomenon: nurses or women providing
care to those in need in their surrounding communities.
As Barbara Ehrenreich and Deidre English (1973) note,
Women have always been healers. They were the unlicensed doctors and anatomists of western history . . .
they were pharmacists, cultivating herbs and exchanging
the secrets of their uses. They were midwives, travelling
from home to home and village to village (p. 3). Today,
with health care dominated by a male-oriented medical
profession, advanced practice nurses (APNs) (especially
those cheeky enough to call themselves doctor even
while clarifying their nursing role and background) are
viewed as nurses pushing the envelopethe envelope of
regulated, standardized nursing practice. The reality is that
the boundaries of professional nursing practice have always
been fluid, with changes in the practice setting speeding
ahead of the educational and regulatory environments. It
has always been those nurses caring for persons and families
who see a need and respondat times in concert with the
medical profession and at times at oddswho are the true
trailblazers of contemporary advanced practice nursing.
This chapter makes the case that, far from being a new
creation, APNs actually predate the founding of modern
professional nursing. A look back into our past reveals
legendary figures always responding to the challenges
of human need, changing the landscape of health care,
and improving the health of the populace. The titles may
changesuch as a doctor of nursing practice (DNP)but
the essence remains the same.
There is a long and rich history of female lay healing with
roots in both European and African cultures. Well into
the 19th century, the female lay healer was the primary
health-care provider for most of the population. Thesharing
of skills and knowledge was seen as ones obligation as a
member of a community. Theseskills were broad based and
might haveincluded midwifery, the use of herbal remedies,
and even bonesetting (Ehrenreich, 2000, p. xxxiii). Laurel
Ulrich, in A Midwifes Tale (1990), notes that when the
diary of the midwife Martha Ballard opens in 1785, . . .
she knew how to manufacture salves, syrups, pills, teas,
ointments, how to prepare an oilemulsion, how to poultice
wounds, dress burns, treat dysentery, sorethroat, frost bite,
measles, colic, whooping cough, chin cough, . . . and the
itch, how to cut an infants tongue, administer a clister
(enema), lance an abscessed breast . . . induce vomiting,
assuage bleeding, reduce swelling and relieve a toothache,
as well as deliver babies (p. 11).
Ulrich notes the tiny headstones marking the graves
of midwife Ballards deceased babies and children as
further evidence of her ability to provide compassionate,
knowledgeable care; she was able to understand the pain
and suffering of others. The emergence of a male medical
establishment in the 19th century marked the beginning
of the end of the era of female lay healers, including midwives. The lay healers saw their role as intertwined with
ones obligations to the community, whereas the emerging
medical class saw healing as a commodity to be bought
and sold (Ehrenreich & English, 1978). Has this really
changed? Are not our current struggles still bound up with
issues of gender, class, social position, and money? Have
we not entered a phase of more radical than ever splits
between the haves and have-nots, with grave consequences
to our social fabric?
Nursing histories (OBrien, 1987) have documented
the emergence of professional nursing in the 19th century
from womens domestic duties and roles, extensions of
the things that women and servants had always done for
their families. Modern nursing is usually pinpointed as
beginning in 1873, the year of the opening of the first three
U.S. training schools for nurses, as an effort on the part
of women reformers to help clean up the mess the male
doctors were making (Ehrenreich, 2000, p. xxxiv). The
incoming nurses, forexample, are credited with introducing
the first bar of soap into Bellevue Hospital in the dark days
when the medical profession was still resisting the germ
theory of disease and aseptic techniques.
The emergence of a strong public health movement
in the 19th century, coupled with the Settlement House
Movement, created a new vista for independent and autonomous nursing practice. The Henry Street Settlement,
a brainchild of a recently graduated trained nurse named
Lillian Wald, was a unique community-based nursing
practice on the lower east side of New York City. Wald
described these nurses who flocked to work with her
at Henry Street Settlement as women of above average
intellectualequipment, of exceptional character, mentality
and scholarship (Daniels, 1989, p. 24). These nurses, as

4 Unit 1 The Evolution of Advanced Practice
regard to perinatal health indicators, was poor (Bigbee &
Amidi-Nouri, 2000). Midwivesunregulated and by
most accounts unprofessionalwere easy scapegoats on
which to blame the problem of poor maternal and infant
outcomes. New York Citys Department of Health commissioned a study that claimed that the New York midwife
was essentially medieval. According to this report, fully
90% were hopelessly dirty, ignorant, and incompetent
(Edgar, 1911, p. 882). There was a concerted movement
away from home births. This was all part of a mass assault
on midwifery by an increasingly powerful medical elite of
obstetricians determined to control the birthing process.
These revelations resulted in the tightening of existing
laws and the creation of new legislation for the licensing
and supervision of midwives (Kobrin, 1984). Several states
passed laws granting legal recognition and regulation of
midwives, resulting in the establishment of schools of
midwifery. One example, the Bellevue School for Midwives
in New York City, lasted until 1935, when the diminishing
need for midwives made it difficult to justify its existence
(Komnenich, 1998). Obstetrical care continued the move
into hospitals in urban areas that did not provide midwifery. For the most part, the advance of nurse-midwifery
has been a slow and arduous struggle often at odds with
mainstream nursing. For example, Lavinia Dock (1901)
wrote that all births must be attended by physicians.
Public health nurses, committed to the professionalizing
of nursing and adherence to scientific standards, chose to
distance themselves from lay midwives. The heritage of
the unprofessional image of the lay midwife would linger
for many years.
A more successful example of midwifery was the
founding of the Frontier Nursing Service (FNS) in 1925
by Myra Breckinridge in Kentucky. Breckinridge, having
been educated as a public health nurse and traveling to
Great Britain to become a certified nurse-midwife(CNM),
pursued a vision of autonomous nurse-midwifery practice.
She aimed to implement the British system in the United
States (always a daunting enterprise on any front). In rural
settings, where doctors were scarce and hospitals virtually
nonexistent, midwifery found more fertile soil. However,
even in these settings, professional nurse-midwifery had
to struggle to bloom.
Breckinridge founded the FNS at a time when the
national maternal death rate stood at 6.7 per 1,000 live
births, one of the highest rates in the Western world. More
has been well documented, enjoyed an exceptional degree
of independence and autonomy in their nursing practice
caring for the poor, often recent immigrants.
In 1893, Wald described a typical day. First, she visited
the Goldberg baby and then Hattie Isaacs, a patient with
consumption to whom she brought flowers. Wald spent
2 hours bathing her (the poor girl had been without this
attention for so long that it took me nearly two hours to
get her skin clean). Next, she inspected some houses on
Hester Street where she found water closets that needed
chloride of lime and notified the appropriate authorities.
In the next house, she found a child with running ears,
which she syringed, showing the mother how to do it
at the same time. In another room, there was a child with
a summer complaint; Wald gave the child bismuth and
tickets for a seaside excursion. After lunch she saw the
OBriens and took the little one, with whooping cough
to play in the back of the Settlement House yard. On the
next floor of that tenement, she found the Costria baby
who had a sore mouth. Wald gave the mother honey
and borax and little cloths to keep it clean (Coss, 1989,
pp. 4344). This was all before 2 p.m.! Far from being
some new invention, midwives, nurse anesthetists, clinical
nurse specialists (CNSs), and nurse practitioners (NPs) are
merely new permutations of these long-standing nursing
commitments and roles.
Throughout the 20th century, nurse-midwifery remained
an anomaly in the U.S. health-care system. Nurse-midwives
attend only a small percentage of all U.S. births. Since the
early decades of the 20th century, physicians laid claim to
being the sole legitimate birth attendants in the United
States (Dye, 1984). This is in contrast to Great Britain and
many other European countries where trained midwives
attend a significant percentage of births. In Europe, homes
remain an accepted place to give birth, whereas hospital
births reign supreme in the United States. In contrast to
Europe, the United States has littlein the way of a tradition
of professional midwifery.
As late as 1910, 50% of all births in the United
States were reportedly attended by midwives, and the
percentage in large cities was often higher. However,
the health status of the U.S. population, particularly in

Chapter 1 Advanced Practice Nursing 5
than 250,000 infants, nearly 1 in 10, died before they
reached their first birthday (U.S. Department of Labor,
1920). The Sheppard-Towner Maternity and Infancy Act,
enacted to provide public funds for maternal and child
health programs, was the first federal legislation passed for
specifically this purpose. Part of the intention of this act
was to provide money to the states to train public health
nurses in midwifery; however, this proved short-lived. By
1929, the bill lapsed; this was attributed by some to major
opposition by the American Medical Association (AMA),
which advocated the establishment of a single standard
of obstetrical care, care that is provided by doctors in
hospital settings (Kobrin, 1984).
Breckinridge saw nurse-midwives working as independent practitioners and continued to advocate home births.
And even more radically, the FNS saw nurse-midwives as
offering complete care to women with normal pregnancies and deliveries. However, even Breckinridge and her
supporters did not advocate the FNS model for cities
where doctors were plentiful and middle-class women
could afford medical care. She stressed that the FNS was
designed for impoverished remotely rural areas without
physicians (Dye, 1984).
The American Association of Nurse-Midwives (AANM)
was founded in 1928, originally as the Kentucky State
Association of Midwives, which was an outgrowth of the
FNS. First organized as a section of the National Organization of Public Health Nurses (NOPHN), the American
College of Nurse-Midwives (ACNM) was incorporated
as an independent specialty nursing organization in 1955
when the NOPHN was subsumed within the National
League for Nursing (NLN). In 1956, the AANM merged
with the college, forming the ACNM as it continues today.
The ACNM sponsored the Journal of Nurse-Midwifery,
implemented an accreditation process of programs in 1962,
and established a certification examination and process
in 1971. This body also currently certifies non-nurses
as midwives and maintains alliances with professional
midwives who are not nurses. As noted by Bigbee and
Amidi-Nouri (2000), CNMs are distinct from other APNs
in that they conceptualize their role as the combination
of two disciplines, nursing and midwifery (p. 12).
At their core, midwives as a group remain focused on
their primary commitment: care of mothers and babies
regardless of setting and ability to pay. Rooted in holistic
care and the most natural approaches possible, in 2015 there
were 11,194 CNMs and 97 certified midwives. In 2014,
CNMs or CMs attended 332,107 births, accounting for
12.1% of all vaginal births and 8.3% of total U.S. births
(National Center for Health Statistics, 2014).
CNMs are licensed, independent health-care providers
with prescriptive authority in all 50 states, the District of
Columbia, American Samoa, Guam, and Puerto Rico. CNMs
are defined as primary care providers under federal law. CMs
are also licensed, independent health-care providers who
have completed the same midwifery education as CNMs.
CMs are authorized to practicein Delaware, Missouri, New
Jersey, New York, and Rhode Island and have prescriptive
authority in NewYork and RhodeIsland. The first accredited
CM education program began in 1996. The CM credential
is not yet recognized in all states.
Although midwives are well-known for attending births,
53.3% of CNMs and CMs identify reproductive care and
33.1% identify primary care as main responsibilities in
their full-time positions. Examples include annual examinations, writing prescriptions, basic nutrition counseling,
parenting education, patient education, and reproductive
health visits.
Nursing made medicine look good. Baer, 1982
Surgical anesthesia was born in the United States in the
mid 19th century. Immediately there were rival claimants
to its discovery (Bankert, 1989). In 1846 at Massachusetts
General Hospital, WilliamT. G. Morton first successfully
demonstrated surgical anesthesia. Nitrous oxide was the
first agent used and adopted by U.S. dentists. Ether and
chloroform followed shortly as agents for use in anesthetizing a patient. One barrier to surgery had been removed.
However, it would take infection control and consistent,
careful techniques in the administration of the various
anesthetic agents for surgery to enter its Golden Age.
It was only then that surgery was transformed from an
act of desperation to a scientific method of dealing with
illness (Rothstein, 1958, p. 258).
For surgeons to advance their specialty, they needed
someone to administer anesthesia with care. However,
anesthesiology lacked medical status; the surgeon collected
the fee. No incentive existed for anyone with a medical

6 Unit 1 The Evolution of Advanced Practice
wanted to replace them to establish their own controls.
Different variants of this old power struggle echo today
in legislative battles over the need for on-site oversight by
an anesthesiologist.
The American Association of Nurse Anesthetists (AANA)
was founded in 1931 by Hodgins and originally named the
National Association for Nurse Anesthetists. This group
voted to affiliate with the American Nurses Association
(ANA), only to beturned away. Asearly as 1909, Florence
Henderson, a successor of Magaws, was invited to present a
paper at the ANA convention, with no subsequentextension
of an invitation to become a member of the organization
(Komnenich, 1998). Thatcher (1953) speculates that organized nursing was fearful that nurse anesthetists could
be charged with practicing medicine, a theme we will see
repeated when weexaminethe history of the development
of the NP role. This rejection led the AANA to affiliate
with the American Hospital Association (AHA).
The relationship between nurse anesthetists and
anesthesiologists has always been, and continues to be,
contentious. Consistent with health-care workforce data
in general, there is a maldistribution of MDs, including
anesthesiologists, who frequently choose to practice in areas
where patients can afford to pay or in desirable areas to live.
Rural areas continue to be underserved as well as indigent
areas in general. CRNAs pick up the slack, doing what
has to be done to meet the needs of underserved patients.
Complicating this picture is that there is an uneven supply
of CRNAs in different geographic areas. As CRNAs retire
later, unwilling to give up lucrative positions, some regions
experience intergenerational hostility as well.
Despite a brief period of relative harmony from 1972
to 1976, when the AANA and the American Society of
Anesthesiologists (ASA) issued the Joint Statement on
Anesthesia Practice, their partnership ended when the
board of directors of the ASA withdrew its support of this
statement, returning to a model that maintained physician
control (Bankert, 1989, pp. 140150).
The Certified Registered Nurse Anesthetist (CRNA)
credential came into existence in 1956. At present, there
are approximately more than 50,000 CRNAs (AANA,
2016),* 41% of whom are males (compared with the
approximately 13% male population in nursing overall, a
figure that has held steady for some time). CRNAs safely
degree to take up the work. Who would administer the
anesthesia? And who would do so reliably and carefully?
There was only one answer: nurses.
In her landmark book Watchful Care: A History of
Americas Nurse Anesthetists (1989), Marianne Bankert
explains how economics changed anesthesia practice.
Physician-anesthetists needed to establish their claim to
a field of practice they had earlier rejected (p. 16), and to
do this it became necessary to deny, ignore, or denigrate
the achievements of their nurse colleagues. The most
intriguing part of her study, she says, was the process by
which a rivaland less moneyedgroup (in this case,
nurses) is rendered historically invisible (p. 16).
St. Marys Hospital, later to become known as the
Mayo Clinic, played an important role in the development of anesthesia. It was here that Alice Magaw,
sometimes referred to as the Mother of Anesthesia,
practiced from 1860 to 1928. In 1899, she published a
paper titled Observations in Anesthesia in Northwestern
Lancet in which she reported giving anesthesia in more
than 3,000 cases (Magaw, 1899). In 1906, she published
another review of more than 14,000 successful anesthesia
cases (Magaw, 1906). Bigbee and Amidi-Nouri (2000)
note, She stressed individual attention for all patients
and identified the experience of anesthetists as critical
elements in quickly responding to the patient (p. 21).
She also paid special attention to her patients psyches:
She believed that suggestion was a great help in producing a comfortable narcosis (Bankert, 1989, p. 32).
She noted that the anesthetist must be able to inspire
confidence in the patient and that much of this depends
on the approach (Bankert, 1989, p. 32). She stressed
preparing the patient for each phase of the experience
and of the need to talk him to sleep with the addition
of as little ether as possible (p. 33). Magaw contended
that hospital-based anesthesia services, as a specialized
field, should remain separate from nursing service administrative structures (Bigbee & Amidi-Nouri, 2000). This
presaged the estrangement that has historically existed
between nurse anesthetists and regular nursing; we see
a nursing specialty with expanded clinical responsibilities
developing outside of mainstream nursing.
The medical specialty of anesthesiology began to gain a
foothold around the turn of the 20th century, led largely
by women physicians. However, these physicians were
unsympathetic to the role of the nurse anesthetists; they *In some states, the title CRNA has been changed to APN-Anesthesia.

Chapter 1 Advanced Practice Nursing 7
In a 1943 speech, Frances Reiter first used the term
nurse-clinician. She believed that practice is the absolute
primary function of our profession and that means the
direct care of patients (Reiter, 1966). The nurse-clinician,
as Reiter conceived the role, consisted of three spheres.
The first sphere, clinical competence, included three
additional dimensions of function, which she termed
care, cure, and counseling. The nurse-clinician was labeled
the Mother Role, in which the nurse protects, teaches,
comforts, and encourages the patient. The second sphere,
as envisioned by Reiter, involved clinical expertise in the
coordination and continuity of the patients care. In the
final sphere, she believed in what she called professional
maturity, wherein the physician and nurse share a mutual
responsibility for the welfare of patients (Reiter, 1966,
p. 277). It was only through such working together that
the patient could best be served and nursing achieve its
greatest potential (Reiter, 1966). Although Reiter believed
that the nurse-clinician should have advanced clinical
competence, she did not specify that the nurse-clinician
should be prepared at the masters level.
In 1943, the National League for Nursing Education
advocated a plan to develop these nurse-clinicians, enlisting
universities to educatethem (Menard, 1987).Traditionally,
advanced education in nursing had focused on functional
areas, that is, nursing education and nursing administration.
Esther Lucile Brown, in her 1948 report Nursing for the
Future, promoted developing clinical specialties in nursing
as a way of strengthening and advancing the profession. The
GI Bill was also available. Nurses in the Armed Services
were eligible to receive funds for their education.
It took the entrance of another strong nurse leader,
Hildegard Peplau, to move these ideas forward to fruition.
In 1953, she had both a vision and a plan: She wanted
to prepare psychiatric nurse clinicians at the graduate
level who could offer direct care to psychiatric patients,
thus helping to close the gap between psychiatric theory
and nursing practice (Callaway, 2002). In addition, as
always there was a great need for health-care providers
of all stripes in psychiatric settings. In her first 2 years
at Rutgers University in New Jersey, Peplau developed a
19-month masters program that prepared only CNSs in
psychiatric nursing. In contrast, existing programs, such
as that at Teachers College in New York City, attempted
to prepare nurses for teaching and supervision in a
10-month program.
administer approximately 43 million anesthetics to patients
each year in the United States according to the AANA
2016 Practice Profile Survey.
Interestingly, theinclusion of large numbers of males in
its ranks has noteased the advance of this venerable nursing
specialty; turf wars between practicing anesthesiologists
and nurse anesthetists remain intense as of this writing,
further aggravated by the incursion of doctor-nurses or
nurse-doctors. Nonetheless, nurse anesthetists continue
to thrive and have situated themselves in the mainstream
of graduate-level nursing education, including a large
portion of programs adapting curriculums leading to the
DNP. Their inclusion in thespectrum of advanced practice
nursing continues to be invigorating for us.
The role of the CNS is the one strand of advanced practice nursing that arose and was nurtured by mainstream
nursing education and nursing organizations. Indeed,
one could say it arose from the very bosom of traditional
nursing practice. As early as 1900, in the American Journal
of Nursing, Katherine DeWitt wrote that the development
of nursing specialties, in her view, responded to a need for
perfection within a limited domain (Sparacino, 1986, p. 1).
According to DeWitt, nursing specialties were a response
to present civilization and modern science [that] demand
a perfection along each line of work formerly unknown
(Sparacino, 1986, p. 1). She argued that the new nurse is
more useful, at least to the patient himself, and ultimately
to the family and community. Her sphere is more limited,
but her patient receives better care (Sparacino, 1986, p. 1).
Historically, nurses weretrained and worked in hospitals
that were structured for the convenience of the doctors
around specific populations of patients. Early on, nurses
initiated guidelines for the care of unique populations and
often garnered a hands-on kind of intimacy, an expertise
in the care of certain patients that was not to be denied.
Caring day in and day out for patients suffering from
similar conditions enabled nurses to develop specialized
and advanced skills not practiced by other nurses. Think
of the nurses who cared exclusively for patients with tuberculosis, syphilis, and polio. Because these conditions
are no longer common, any nursing expertise that might
have been developed has been lost.

8 Unit 1 The Evolution of Advanced Practice
had 24-hour responsibility for a patient area and who was
on call. Laura Simms at Cornell UniversityNew York
Hospital School of Nursing developed aCNS roleto provide
consultation to more generalist nurses. As opposed to the
nurse who might have been expert in procedures, these new
clinicians wereexperts in clinical carefor a certain population
of patients.This development occurred across specialties and
was seen in oncology, nephrology, psychiatry, and intensive
care units (Sills, 1983).
Roleexpansion of theCNS grew rapidly during the 1960s
because of several factors. Advances in medical technology
and medical specialization increased the need for nurses who
were competent to care for patients with complex health
needs. Nurses returning from the battlefields of Vietnam
sought to increase their knowledge and skills and continued to practice in advanced roles and nontraditional areas
(such as trauma or anesthesia). Role definitions for women
loosened and expanded.There was a shortage of physicians.
The NurseTraining Act of 1964 allocated necessary federal
funds for additional graduate nursing education programs in
several different clinical specialties (Mirr & Snyder, 1995).
The terms nurse-clinician, CNS, and nurse specialist,
among others, were used extensively by nurses with experience or advanced knowledge who had developed an
expertise within a given area of patient care. There were no
standards regarding educational requirements orexperience.
In 1965, the ANA developed a position statement declaring
that only those nurses with a masters degree or higher in
nursing should claim therole of CNS (ANA, 1965). These
trends continued into the 1970s. The number of academic
programs providing masters preparation in a variety of
practice areas increased. Federal grants, including those
from the Department of Health, Education, and Welfare,
continued to providefunding for nursing education at the
masters and doctoral levels.
In 1976, during the ANAs Congress on Nursing
Practice, a position statement on the role of the CNS was
issued. The ANA position statement read as follows (ANA
Congress for Nursing Practice, 1976):
The clinical nurse specialist (CNS) is a practitioner holding
a masters degree with a concentration in specific areas of
clinical nursing. The role of the CNS is defined by the needs
of a select client population, the expectation of the larger
society and the clinical expertise of the nurse.
The statement went on to elaborate that by exercising
leadership ability and judgment, the CNS is able to affect
The field of psychiatric nursing was in the process of
inventing itself. Before the passage of the National Mental
Health Act in 1946, there was no such field as psychiatric
nursing. It was the availability of National Institute of Mental
Health funds to seed such programs as Peplaus that allowed
psychiatric nursing to begin and eventually to flourish.
In retrospect, Peplau would note that no encouragement
was received from the two major nursing organizations
of the day, the NLN and the ANA. She stated, We were
highly stigmatized. Any nurse who worked in [the field
of mental health] was considered almost certifiable. . . .
We were thoroughly unpopular, we were considered queer
enough to be avoided (Callaway, 2002, p. 229).
It should be emphasized that at this point in nursing
history it was inconceivable that any nurse, under any
circumstances, could become a specialist. The received
wisdom of the day was the axiom, followed by the vast
majority of nurses, that a nurse is a nurse is a nurse,
opposing any differentiation between who was doing
what among them. Peplaus rigorous curriculum and
clinical and academic program requirements expected
that faculty would continue their own clinical practice,
do clinical research, and publish the results (Callaway,
2002). This was a radical model for nursing faculty, few
of whom were doctorally prepared in the 1950s. In 1956,
only 2 years following the initiation of the first clinically
focused graduate program, a national working conference
on graduate education in psychiatric nursing formally
developed the role of the psychiatric clinical specialist.
Most hospital training schools remained embedded in
a functional method of nursing well into the 1960s. As
originally conceptualized by Isabel Stewart in the 1930s,
nurses were trained and much of nursing practice was
rule-based and activity-oriented (Fairman, 1999, p. 42),
relying heavily on repetition of skills and procedures. There
was little, if any, scientific understanding of the principles
underlying care. There was little, if any, intellectual content
to be found in the nursing curriculum.
With the advent of antibiotics in the 1940s and theresulting
decline of infectious diseases, nurses practiceshifted to caring
for patients with acute, often rapidly changing exacerbations
of chronic conditions. Leaders such as Peplau, along with
others such asVirginia Henderson, Frances Reiter, and later
Dorothy Smith, began developing a theoretical orientation
for practice. Students were being taught to assess patient
responses to their illnesses and to make analytical decisions.
Smith experimented with theidea of a nurse-clinician who

Chapter 1 Advanced Practice Nursing 9
the Council of Nurses in Advanced Practice (Busen &
Engleman, 1996; Lincoln, 2000). Following the merger
of the councils, several studies were published comparing
CNS and NP roles, finding the education for practice
generally comparable (Joel, 2011).
The 1990s was an era of health-care reform. Health-care
costs were skyrocketing; hospital stays were shorter, with
acutely ill patients being discharged quicker and sicker.
Because of fiscal mandates, hospitals were decreasing the
number of beds and personnel and the focus of health
care shifted from hospital to ambulatory care within the
community and home. The historically hospital-based
CNS was considered too expensive and unproven. Thus,
CNSs all over were losing positions.
In 1993, the American Association of Colleges of
Nursing (AACN) met to discuss educational needs and
requirements for the 21st century. At the AACNs annual
conferencein December 1994, members voted to support
the merging of the CNS and NP roles in the curricula of
graduate education in nursing. Although the structure
of the curricula suggested in the Essentials of Graduate
Education (AACN, 1995) has been widely adopted, the
lived reality of role adaptation and its implementation
in the marketplace has been less uniform and more divisive. Sparacino (1990) defined the scope of the CNS as
client-centered practice, utilizing an in-depth assessment,
practiced within the domain of secondary and tertiary care
settings (p. 8). The NP roleis defined by Sparacino (1986)
as being responsible for providing a full range of primary
health-careservices, using the appropriate knowledge base
and practicing in multiplesettings outside of secondary and
tertiary settings.To some degreethis has been the nature of
theseroles, though many exceptions can be observed today.
Scope of practice barriers continue in this area of
advanced practice nursing. The latest setback occurred
when the Standard Occupational Classification Policy
Committee (SOCPC) announced its recommendations
to the Office of Management and Budget for the 2018
Standard Occupational Classification on July 22, 2016.
The SOCPC declined to include the CNS in a separate
broad occupation and detailed occupation category, stating:
Multiple dockets requested a new detailed occupation for
Clinical Nurse Specialists. The SOCPC did not accept this
recommendation based on Classification Principle 2 which
states that occupations are classified based on work performed
and on Classification Principle 9 on collectability.
client care on the individual, direct-care provider level as
well as affect change within the broader health-care system
(ANA Congress for Nursing Practice, 1976).
The 1970s were a time of growth in academic CNS
programs; the 1980s were years in which refinements
occurred. In 1980, the ANA revised its earlier policy
statement of 1976 to define the CNS as a registered
nurse who, through study and supervised clinical practice
at the graduate level (masters or doctorate) has become
an expert in a defined area of knowledge and practice in
a selected clinical area of nursing (ANA, 1980, p. 23).
This statement was significant because it was the first time
that education at the masters level had been dictated as a
mandatory criterion for entry into expert practice.
The CNS role more than any other advanced nursing
role was situated in the mainstream of graduate nursing
education, with the first masters degree in psychiatric and
mental health nursing conferred by Rutgers University in
1955. The inclusion of clinical content in masters degree
education was an essential step forward for nursings advancement. But the implementation and use of the CNS
avoided easy categorization and their efficacy was elusive.
In February 1983, the ANA Council of Clinical Nurse
Specialists met for the first time (Sparacino, 1990). The
Council grew rapidly throughout the subsequent years,
supporting and providing educational conferences for the
increasing numbers of CNSs. In 1986, the Council published the CNSs role statement. This statement identified
the roles of the CNS as specialist in clinical practice and as
educator, consultant, researcher, and administrator. This
role statement by the Council depicted the changing role
of the CNS, notably delegating and overseeing practice as
its primary focus (Fulton, 2002). The year 1986 was also
notable for the publication of the journal Clinical Nurse
Specialist: The Journal for Advanced Nursing.
In 1986, the ANAs Council of Clinical Nurse Specialists
and the Council of Primary Health Care Providers published an editorial outlining thesimilarities of the CNS and
NP roles. Discussion surrounding the commonalities of
both specialties occurred throughout the decade. In 1989,
during the annual meeting of the National Organization
of Nurse Practitioner Faculty (NONPF), the 10-year-old
debate regarding the merger of the two roles reached a
crescendo without resolution (Lincoln, 2000). It remains
an issue of contention to the present day. Despite this,
the two ANA councils did merge in 1990, becoming

10 Unit 1 The Evolution of Advanced Practice
Jacox, 2002). A lesser known story involves Dr. Eugene A.
Stead, Jr., of Duke University, who in 1957 conceived of
an advanced role for nurses somewhere between the role of
the nurse and the doctor. Thelma Ingles, a nursing faculty
member on a sabbatical, worked with Stead, accompanying
the interns and residents on rounds, seeing patients, and
managing increasingly ill patients with acumen and sensitivity. Ingles shared Steads ideas and returned to the Duke
Nursing School to create a master of science in nursing
program modeled on her experience with Stead. Stead
was gratified and anxious to impart this expanded role to
other nursing faculty, envisioning a new role for nurses,
with, in his view, expanded autonomy. He was shocked at
the lukewarm response of the dean of nursing at Duke
and the unsupportive stance of several prominent nurses
at the university. On top of that, the NLN, the schools
accrediting body, did not approve of Ingless new program
for nurse clinical specialization and withheld the programs
accreditation. They found the program unstructured and
criticized the use of physicians as instructors to teach courses
for nurses in a nursing program. They disavowed the study
of the esteemed discipline of medicine that Stead was so
anxious to impart (Holt, 1998). Instead, they wanted the
students to study nursing. Stead could not understand
this. What was there in nursing to study? Rejected and
disheartened, Stead eventually turned to military corpsmen to actualize this new role, which he named physician
assistant. He insisted that they be male. In his view, nurse
leaders were very antagonistic to innovation and change
(Christman, 1998). In the view of some, this was a missed
opportunity for organized nursing but one governed by
historical circumstances when viewed on the broader stage
of history. Fairman (2008), in an extensive study of Steads
papers, offers the appraisement that Steads difficulties
went beyond his experiences with organized and academic
nursing. They reflected his perceptions of the kind of help
his physician colleagues needed (Fairman, 2008, p. 98).
Steads original proposal was quite prescient. Gender
roles were loosening as were hierarchical structures in
general; nurses were better educated and well able to
assume the role responsibilities that Stead envisioned.
Yet it came at a time when nursing was merely a fledgling
discipline, new to the university, new to development as
an academic discipline, and new to doctoral education.
Academic nursing was fixated on defining its own knowledge base and developing its own unique science. Along
In July 2014, the National Association of Clinical Nurse
Specialists (NACNS) submitted an extensive filing on why
the CNS should beincluded in the Standard Occupational
Classification (SOC) as a broad category. This is thesecond
time that the SOCPC did not accept the request to make
the CNS a new detailed occupation in the SOC. Retaining
CNSs in the RNs 2010 classifications is inconsistent with
federal agencies, with nursing practice in the states, and
with thelarger nursing community, all of which distinguish
CNSs as APRNs. Congress has accepted CNSs as APRNs
for nearly two decades. The Balanced Budget Act of 1997
allowed CNSs to directly bill their services through the
Centers for Medicare and Medicaid Services under Part B
participation in Medicare. CNSs were recognized as eligible for Medicares Primary Care Incentive Program in the
Patient Protection and Affordable Care Act (PPACA, 2010).
CNSs prescribe medications, durable medical equipment, and medical supplies as well as order, perform, and
interpret diagnostic tests including laboratory work and
x-rays. Two unequivocal differences exist between CNSs
and RNs: diagnosing patients and prescribing pharmaceuticals. CNSs can perform both; RNs are not authorized
to perform either. The SOCPCs recommendation to not
recognize the CNS as a broad occupation and detailed
occupation, similar to how other APRNs are categorized,
skews the quality and utility of federal health-care policy
data. Linking the CNS workforce data with the RN workforce does not allow CNS contributions to be differentiated
from or compared with any other APRN data. Simply
put, a database set up by any federal, state, regional, local,
research, or private entity using the 2010 SOC categories
has no data on the more than 72,000 CNSs in the United
States (NACNS, 2016).
The other side of this story of advanced practice
nursingNP evolutionis addressed in the next section
of this chapter. The futures of these various roles remain on
some level intertwined and are further complicated by the
emergence of a newmodel ofeducational preparation: theDNP.
The history of the NP movement has been well documented (Brush & Capezuti, 1996; Fairman, 1999, 2008;

Chapter 1 Advanced Practice Nursing 11
Ford states thefollowing in an interview: Welooked at
the nurse practitioner preparation not as a separate program
but as integrated into a rolethat had already been designed
at the graduate level (Jacox, 2002, p. 155). Ford notes
that thelack of organizational leadership in the profession
coupled with a lack of responsiveness in academic settings
caused a bastardization of the model (Jacox, 2002, p. 157).
She had envisioned that our professional organization, as
in other professions, would identify, credential, and make
public advanced NPs. However, Ford was to discover that
the ANA in those early years was reluctant to stick its
neck out and give some leadership to the NP groups that
were growing rapidly and that the lack of leadership in
nursing education created a patchwork quilt of differently
prepared NPs (Jacox, 2002, p. 157). Although clinically
based programs were growing, there remained resistance
to the NP model. Ford (Jacox, 2002, p. 155) says,
I understood that faculty members weresupposed to be doing
just thatpush the borders of knowledge and publish their
work. In my naivet of faculty politics, I expected that since
the NP model grew out of professional nursing and public
health nursingincluding primary, secondary, and tertiary
prevention and community-based servicesit was a perfectly
legitimate investigation. Instead, it became a battleground,
and even recently was labeled in the Harvard Business Review
as a Disruptive Innovation. What a compliment!
The collaboration between NP and physician has been
analyzed and debated since the advent of the NP role, including therelationship between Ford and Silver (Fairman,
2002, 2008). The sticking point of collaboration is that
it has included the heavy implication of supervision and
thus control. In truth, in the early 1970s both NPs and
physicians had to give up their traditional roles, tasks,
and knowledge to establish this new provider role, often
in the face of organizational and societal opposition. Jan
Towers describes the growth of her own NP practice as
follows: The area that I perhaps most feared turned out
to be the least troublesome, after some initial adjustments
between the physician with whom I was working and me
were made (Towers, 1995, p. 269). What would often
be impossible on an organizational level was more easily
resolvable among professionals with a shared interest and
commitment: the good of the patient.
Prescriptive authority was a major issue, and it was
either delegated from the medical practice act and carried
out under physicians standing orders or protocols or it
with expanded opportunities for women came ideas of
an autonomous nursing role separate and distinct from
medicine. Steads deeply rooted gender-role stereotyping
no doubt further inflamed nursing resistance to his new
role. Other settingssuch as the University of Colorado,
where Henry Silver, a pediatrician, and Loretta Ford, a
masters-prepared public health nurse, founded a partnership rooted in collaborationprovided more fruitful
results. All these factors were in play when the first NPs
emerged in the 1960s.
However, the NP was not really a new role for nurses.
Examining our history, it is apparent that nurses functioned independently and autonomously before the rise
of organized medicine. If medicine was ambivalent about
the emergence of this new role, nursing itself was no less
In 1978, thefollowing statement appeared in the American
Journal of Nursing (Roy & Obloy, 1978, p. 1698):
The nurse practitioner movement has become an issue in
nursing, a topic on which thereis no consensus. One question
about the movement is whether the development of the nurse
practitioner role adds to, or detracts from, the development
of nursing as a distinct scientific discipline.
This statement was issued more than 13 years after
the initiation of the first NP program at the University of
Colorado. If, as Sparacino (1990) spells out, the domain of
the CNS is situated in the secondary and tertiary setting,
the domain of the NP originally arose as a role situated
in primary care.
Loretta Ford and Dr. Henry Silver designed a graduate
curriculum for pediatric nurses to provide ambulatory
care to poor rural Colorado children. The goal of this
program was to bridge the gap between the health-care
needs of children and the familys ability to access and
afford primary health care (Ford & Silver, 1967; Silver,
Ford, & Stearly, 1967). This program was situated in
graduate education and included courses such as pathophysiology, health promotion, and growth and development, with the intent of the student understanding the
principles of healthy child care and patient education.
Nurses would then be able to provide preventive nursing
services outside of the hospital setting in collaboration
with physicians. Students had to have a baccalaureate
degree and public health nursing experience to be admitted to the program.

12 Unit 1 The Evolution of Advanced Practice
Government and private groups rapidly developed funding
support for educational programs (Hamric, Spross, &
Hanson, 2013). According to Marchione and Garland
(1997), The traditional role of humanistic caring, comforting, nurturing and supporting was to be maintained
and improved by the addition of new primary care
functions that the Department of Health, Education, and
Welfare approved: total patient assessment, monitoring,
health promotion, and a focus that encompassed not only
disease prevention but health promotion and maintenance,
treatment, and continuity of care.
The Division of Nursing of the Department of Health,
Education, and Welfare tracked the development of the
NP rolefrom 1974 to 1977. During that time, the number
of NP programs rose from 86 to 178 across the country,
with significant governmental support through the Nurse
Training Act to advanced practice nursing education
programs of all types. Although nurse educators by this
time wanted NP education standardized, in 1977 most
NP programs awarded a certificate with some still using
continuing education models and accepting less than a
baccalaureate degree for entry. However, the number of
NP graduates of masters programs did increase from 20%
in 1975 to 26% in 1977, again largely encouraged by the
availability of federal funds for support. The education
of NPs was the rallying cry for the formation of the
NONPF in 1980, dedicated to defining curriculum and
evaluation standards as well as pioneering research and
development related to NP practice and teaching-learning
methodologies. The political voice for NPs was enhanced
with the formation of the American Academy of Nurse
Practitioners (AANP) in 1985 and the American College
of Nurse Practitioners (ACNP) in 2003.
The NurseTraining Acts of 1971 and 1975 were critical
in providing federal funding to support NP programs. By
1979, more than 133 programs and tracks existed, and
approximately 15,000 NPs were in practice. By 1983 and
1984, NP graduates numbered approximately 20,000
to 24,000; they were primarily employed in sites that
served those in greatest need: public health departments,
community health centers, outpatient and rural clinics,
health maintenance organizations, school-based clinics, and
occupational health clinics (Hamric et al, 2013; Kalisch &
Kalisch, 1986; Pulcini & Wagner, 2001). NPs weretypically
providing care for health promotion, disease prevention,
minor acute problems, chronic stabilized illness, and the
came directly from the nursing practice acts. Nurse historian Arlene Keeling has argued that far from being a new
realm of nursing practice, the prescribingor useof
a variety of techniques and substances for therapeutic
effect has always been a dimension of nursing practice
(Keeling, 2007). The states of Oregon and Washington
allowed nurses the freedom to prescribe independently in
1983 (Kalisch & Kalisch, 1986). Some of the fiercest turf
battles have heated up over prescriptive privileges. By 1984,
nurses were accused of practicing medicine, although they
were practicing well within the scope of their expanded
role. Physicians remained ambivalent. They pushed NPs
to function broadly but did not usually support legislation
that authorized an increased scope of practice, especially
in the area of prescriptive privileges. Joan Lynaugh, nurse
historian, describes NPs as looking for an exam room of
their ownessentially a clinical space in which to provide
nursing care (Fairman, 2008, p. 7). This space is indeed a
crowded one (Fairman, 2008, p. 200, note 9). Prescriptive
authority is discussed in greater detail in Chapter 6.
The Great Society entitlement programs significantly
influenced the need for NPs to care for people who were
covered under Medicare and Medicaid. Predominant social
movementswomens rights, civil rights, antiwar protest,
consumerismhad a profound impact on the need for groups
to assert their place in the society of the 1960s and early
1970s. Nurses were not immuneto theforces unleashed in
these years and took advantage of the opportunities to work
with physicians in relationships that were entrepreneurial
and groundbreaking, and to engage in a kind of dialogue
that supported new models of care (Fairman, 2002, p. 165).
These nurses were pioneers, rebels, and renegades treading
on uncertain ground.
The National Advisory Commission on Health
Manpower supported the NP movement (Moxley, 1968).
The Committee to Study Extended Roles for Nurses in
the early 1970s recommended that the expanded role
for nurses was necessary to provide the consumer with
access to health care and proposed the inclusion of highly
developed health assessment skills (Kalisch & Kalisch,
1986; Leininger, Little, & Carnevali, 1972; Marchione &
Garland, 1997). Although the Committee did stop short
of providing a definitive scope of practice statement, it
recommended support for licensure and certification for
advanced practice, recognition in the nursing practice act,
further cost-benefit research, and surveys on role impact.

Chapter 1 Advanced Practice Nursing 13
the National Council of State Boards of Nursing (NCSBN)
gave direction for gains in legal authority, prescriptive privilege, and reimbursement mechanisms across the 50 states
and the District of Columbia. Current NPs have achieved
a higher degree of autonomy in practice and associated
prestige (Phillips, 2011) with the mandate for continued
advancement contained in the IOM report, The Future
of Nursing (2011). More victories than failures provide
evidence of success, but, as in the late 1970s, todays NP
is still battling for autonomy and consumer recognition in
practice,especially in states with many physicians. Veterans
Health Affairs (VHA) Advanced Practice Registered Nurses
Proposed Rule (81 Fed.Reg.33155, May 25, 2016) to
the Federal Register is under siege. Opponents, as noted
earlier, are still trying to block implementation of this
policy and are reaching out to members of Congress to
delay the proposal through legislation that extends expiring benefits for our nations veterans. New legislation
was introduced late in 2016, the Veterans Affairs Expiring
Authorities Act (HR 5985).
As early as 1985, Hayes stated, No role in nursing,
or for that matter, in any field has been so debated in the
literature, and possibly no other nursing function has ever
been so obsessed about by those performing it as has been
the NP role (Hayes, 1985, p. 145). Yet, as Hayes asserts,
there has been an avalanche of support from satisfied
consumers of NP services.
In an effort to bring some clarity to and standardization
of advanced practice nursing roles, in 2008 the APRN
Consensus Model, also referred to as a regulatory model,
was published by the APRN Consensus Work Group and
the NCSBN APRN Advisory Committee with extensive
input from a larger APRN stakeholder community. The
nomenclature APRN was adopted, and four APRN roles
were defined in the document: CNMs, CRNAs, CNSs,
and certified nurse practitioners (CNPs). An APRN is
further defined as an RN who has completed a graduate
degree or postgraduate program that has prepared him
or her to practice in one of these four roles. The acronym
LACEstanding for licensure, accreditation, certification, and educationdemonstrates alliances across these
spheres for implementation of the APRN Consensus
full range of teaching and coaching that nurses have always
provided for patients and families.
A hindrance to practice in rural areas was finding appropriate physician backup. By 1987, the federal government had spent $100 million to promote NP education,
primarily through the U.S. Public Health Service Division
of Nursing (Pulcini & Wagner, 2001). By the 1980s, the
masters degree was viewed broadly as the educational
standard for advanced practice (Geolot, 1987; Sultz et al,
1983), and by 1989, 90% of programs were masters and
post-masters level (Pulcini & Wagner, 2001). NONPF
thrived in the 1980s, developing curriculum guidelines
and competencies, surveying faculties, and studying role
An interorganizational task force to identify criteria for
quality NP educational programs occurred as an outgrowth
of the work to unify certification. This work, begun in
1995 by NONPF and the NLN, was the beginning of
the development of a model curriculum for NP education that would be used nationally and provide the basis
for certification eligibility (Hamric et al, 2013). At that
time, the NLN was the only accrediting body for nursing
graduate programs, and program standards, curriculum
guides, and domains and competencies for NP education
from NONPF were often used by the NLN in the accreditation process. In 1998, the Commission on Collegiate
Nursing Education, an accreditation arm of the AACN,
was formed to provide an alternative to the NLN as a
source of accreditation to schools offering baccalaureate
and higher degrees in nursing. The thrust of the 2001
meeting of the NP task force when it reconvened was for
accrediting bodies to movetoward the approval of NONPF
guidelines and standards as the reigning accepted standards
for accreditation of programs preparing NPs (Edwards
et al, 2003). In addition, the APRN Consensus Model
(see later section) spells out specific criteria for preapproval
and accreditation of APRN education.
There is a cautionary note to this perception of progress. Despite clear statutes in some states, credentialing
by insurers for NPs may still lag, providing additional
barriers to care. Scope of practice, a primary focus of
the 2011 Institute of Medicine (IOM) Future of Nursing
recommendations, remains a contested battleground for
control of professional practice and reimbursement.
In 2008, the adoption of the Consensus Model for
Advanced Practice Registered Nurse(APRN) Regulation by

14 Unit 1 The Evolution of Advanced Practice
The case can also be made that APNs across the country have been expanding their skills, both formally and
informally. One example is the role of intensivist in
the hospital, which is being assumed by many NPs and
CNSs (Mundinger, 2005). This is consistent with nursings lengthy history of moving where the need in health
care surfacesalways doing what had to be done. The
aging of the population, the increased acuity of patients
with multiple comorbidities, the complexity of care, the
continuation of a dwindling number of primary care
physicians, and the decreased hours for residents in the
hospital because of legislative and accreditation criteria have
fostered the need for these nurses to move well beyond
the primary care arena. For example, when Columbia
University School of Nursing was asked by Presbyterian
Hospital to establish two new ambulatory care clinics to
meet the growing demand for primary care among the
underserved immigrant populations, the faculty accepted.
They also proposed conducting a randomized trial comparing independent NPs and primary care physicians.To
reduce the variability among roles and strengthen the study,
the faculty requested that the hospitals medical board
grant the faculty NPs admitting privileges. Mundinger
(2005) describes this evolution at Columbia: Several
physician(s) . . . provided additional training for our
faculty nurse practitioners in dermatology, radiology, and
cardiology and helped mentor them through the process
of admitting, and co-managing patients and conducting
emergency room evaluation (p. 175).
The results of the randomized trials, with excellent
patient care outcomes achieved by NPs on a par with
primary care physicians, were published in the Journal of
the American Medical Association (Mundinger et al, 2000).
This contributed to a change in hospital bylaws and granted
faculty NPs hospital admitting privileges. Mundinger
sees the level of service delivered by these faculty NPs as
beyond that achieved by colleagues with the traditional
masters degree preparation for practice. Based on these
observations comes the call for a formal and standardized
curriculum leading to a doctoral degree consistent with the
practice needs for advanced competencies and increased
knowledge. Mundinger (2005) states, We know that
thousands of nurses aspire to this level of education and
schools are responding by developing the new degree.
We know that the research degree is asynchronous with
these goals, and we know from every other profession that
Model, thus promoting uniformity and standardization
of the APRN role for the safety of the consumer of health
care. The target date for model implementation was 2015,
with an alignment of current certifying examinations with
educational program offerings and subsequent licensure.
By December 2016, according to the NCSBN, 15 states
were in full compliance with the LACE model and most
others were in some stage of change. This is amazing given
the continued strength of states rights and the opposition
of organized medicine.
The future contains clouds on the horizon as well as
sunshine. Fairman (1999) cautions that although local
negotiations between individual physicians and nurses
may have been, in some cases, easily traversed in the
interest of the good of the patient, on the professional
level hierarchical relationships and power are at stake.
As noted at the start of this chapter, within this hotly
competitive health-care environment, with the still
controversial implementation of the PPACA (2010),
the entire health-care sector continues to face hurdles,
challenges, and assaults.
In October 2004, the members of the AACN endorsed the Position Statement on the Practice Doctorate in
Nursing, which called for the movement of educational
preparation for advanced practice nursing roles from the
masters degree to the doctoral level by 2015. Though this
target date has not been achieved, there has been much
movement in this direction. This new doctorate is a
practice doctorate in contrast to the doctor of philosophy (PhD)the traditional research degreeand is not
intended to replace the PhD. There are many reasons
for this development. Some masters programs for APNs
had become very lengthy, without any change in the credential awarded at the completion of studies. The number
of credits, in many cases, approaches what is required
for a doctoral degree. And many educators believe this
is necessary to ensure clinical competency. Furthermore,
other practice disciplines such as pharmacy, physiotherapy,
and occupational therapy have moved on to doctoral-level
preparation. The debate continues.

Chapter 1 Advanced Practice Nursing 15
RN, DrPH, FAAN. This report was presented in November
2010. The far-reaching impact of the reports recommendations are just now beginning to be fully absorbed. Key
recommendations begin with the assumption that nursing can fill . . . new and expanded roles in a redesigned
healthcare system (IOM, 2011, p. xi). We will need our
renegades, rebels, and trailblazers more than ever.
The boundaries of practice are always malleable. They
are always subject to myriad external forcespolitical,
economic, social, and culturaland are interpreted in
different ways by different practitioners. APNs are a mixed
breed; each trajectory under the umbrella of advanced
nursing practice has evolved differently and under variable
circumstances. This leads to vigor, strength, and diversity.
The struggles documented within this chapter have aimed
to strengthen each variant of the nursing advanced practice
role. The struggles are not over; in many ways, they are
just beginning. It is our hope that nursing will continue
to produce rebels, renegades, and trailblazers motivated by
concern for patients, concern for community, and concern
for humanity. We have no doubt that we will continue
to take on new and challenging roles using creative and
diverse strategies. Nursing continues to lurch forward;
progress is sometimes slow, sometimes variable, sometimes
unsteadybut, as always, continuing to find opportunity
in chaos, motivated, as ever, by commitment to patients,
families, and communities, to human need and suffering.
when you reach the competency associated with doctoral
achievement, one should receive a doctorate not another
MS degree (p. 175).
As part of the APRN Consensus Model, 2015 was
targeted as the year anyone seeking to sit for certification
as an APRN would need a DNP. Although the DNP
degree has spread and prospered since 2008, there have
always been vocal detractors. Recently, opposition to this
mandate was voiced by a significant cohort of national
nursing leaders in a paper titled The Doctor of Nursing
Practice: A National Workforce Perspective (Cronenwett
et al, 2011), making the case that the need for care providers should take precedence over a professionalizing
agenda. Significant retrenchment of the 2015 mandate
has occurred, with moves to preserve existing masters
programs producing APRNs. See Chapter 4 for more
discussion on this issue.
This dramatic, evidence-based report presents the results
of 2 years of study by the Committee on the Robert Wood
Johnson Foundation Initiative on the Future of Nursing at
the IOM. This committee was chaired by Donna Shalala,
PhD, FAAN, long-time nurse advocate, former head of
the U.S. Department of Health and Human Services
(19922000), and now University of Miami president,
in concert with Nursing Vice Chair Linda Burnes Bolton,

Emerging Roles of the Advanced
Practice Nurse
Deborah Becker and Caroline Doherty
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Describe the advanced practice registered nurses (APRN) Scope of
Practice and the Consensus Model.
Describe the clinical nurse specialist (CNS) role and discuss how their
contributions contribute to cost savings and implementation of
evidence-based practice.
Identify role highlights of the nurse practitioner (NP) in primary care with
adult and pediatric populations, in various community settings, in psychiatric
and mental health care, in womens health/gender-related care and
transitional care, and in acute care with neonatal, pediatric adult,
and elderly populations.
Discuss nurse-midwifery with an emphasis on primary care
and first-assistant services.
Summarize the new certification requirements for nurse
Distinguish palliative care as an emerging practice area
for all APRNs.
Propose diverse practice opportunities for APRNs.

Chapter 2 Emerging Roles of the Advanced Practice Nurse 17
A systematic review of outcomes studies conducted
between 1990 and 2008 was performed to compare patient outcomes between physician- and APRN-directed
teams (Newhouse et al, 2011). The review found that
patient outcomes of care provided by NPs and CNMs
(in collaboration with physicians as required by state
regulations) were similar toand in some ways better
thancare provided by physicians alone for the populations and in the settings included (Newhouse et al,
2011). The review found that CNSs working in acute
care settings can reduce length of stay and cost of care
for hospitalized patients. Although no specific conclusions regarding CRNA patient outcomes were provided
by this review, a few studies show CRNA patient outcomes to be comparable with those of anesthesiologists
(Newhouse et al, 2011). A recent Cochrane Review of
studies comparing outcomes of anesthesiologists and
CRNAs found that, although the quality of studies
available to review was poor, there is no available study
demonstrating any difference between the quality of
care provided by CRNAs or anesthesiologists (Lewis,
Nicholson, Smith, & Alderson, 2014).
By accepting theresponsibilities of the advanced practice
role, APRNs have understood the need to expand legislative recognition of their professional status, including
prescriptive authority and reimbursement for care delivered.
Recognition of APRNs in the United States varies, with
most states providing some level of legal recognition and
prescriptive authority.
Advanced practice nursing continues to evolve to meet
the changing and increasing needs of patients, communities, and society as a whole. Advanced practice registered
nurses (APRNs)* have successfully adapted their roles to
meet these ever-changing needs and the expectations that
go along with them. The growth occurring now can be
attributed to several elements, such as health-care reform
and fuller implementation of the Affordable Care Act
(ACA), a national emphasis on the provision of safe and
high-quality care, pay-for-performance initiatives, and
the call by the Institute of Medicine (IOM)s Future of
Nursing (2011) report for APRNs to work to the fullest
extent of their scopes of practice without restrictions or
barriers. These initiatives foster new opportunities for the
development of advanced practice nursing roles.
Several factors have influenced the emergence and
acceptability of advanced practice roles. These factors
include the growing numbers of elderly patients as baby
boomers reach retirement age, increased complexity and
severity of illness in hospitalized patients, further reductions in medical residents clinical work hours, a call for
greater access to care for all citizens, and a varying degree
of nursing and primary care physician shortages, depending on geographical region. These and other factors will
continue to influence the emergence of the APRN role
in the coming decades.
The four major groups of APRNs currently in the
United States are certified registered nurse anesthetists
(CRNAs), certified nurse-midwives (CNMs), clinical
nurse specialists (CNSs), and nurse practitioners (NPs).
The range of current advanced practice roles and the
numbers of nurses in these roles demonstrate the continued success and acceptance of APRNs. See Table 2.1.
Studies evaluating clinical outcomes of care delivered
by APRNs are overwhelmingly positive as are surveys of
patient satisfaction with the delivery of care by APRNs.
*APRN is the title preferred by the American Nurses Association (ANA) and
used in most state practice acts. Throughout this chapter, various acronyms will be presented to distinguish between specialty preparations, but
the generic title for all these practice roles is APRN. Please note that not all
of the four specialty preparations are recognized in their state as APRNs.
Table 2.1
Numbers of Advanced Practice Nurses
Clinical nurse specialists 8,395
Certified registered nurse anesthetists 49,113
Certified nurse-midwives 8,332
Nurse practitioners 186,656
Source: Adapted from Phillips, S. J. (2016). 28th annual legislative update.
Nurse Practitioner, 41(1), 2152.

18 Unit 1 The Evolution of Advanced Practice
Professional nursing organizations and state boards of
nursing understand the need to describe and interpret
the responsibilities of advanced practitioners in their
areas of specialization. Underlying the recognition of this
need is the obligation to ensure public safety, to identify
the essential characteristics of advanced practice, and to
interpret for the practitioner the components of competent
care (American Association of Critical Care Nurses and
American Nurses Association, 1995). The scope of practice may be described by the functions performed by the
APRN and the minimal competencies needed to perform
those functions. These descriptions and guidelines direct
APRNs in the implementation and conceptualization of
their roles and responsibilities.
In addition, each state has a legislative and regulatory
stance on issues affecting advanced practice within its
jurisdiction (Phillips, 2016). The legal scope of practice,
including prerogatives for diagnosing, prescriptive authority,
and reimbursement, is described within these regulations.
Scope and standards of practice are defined by the professional organization and enacted into law at the state level.
The actual role is further delineated through credentialing
of practice responsibilities and activities at the institutional
or employment level. Hospitals and other health-care
organizations typically define role responsibilities and
prerogatives through a review by other practitioners, and
this is generally expressed through a contract identifying
responsibilities, prerogatives, and limitations of the role.
This review results in the granting of institutional- or
organizational-based practice privileges for the APRN.
Although scope of practice guidelines are important
philosophically and may even have the weight of law, they
do not imply that theroles of APRNs are unchanging.When
knowledgeevolves and different care delivery modelsemerge,
roles also evolve. More commonly, roles change as different
practicesettings become available and opportunities forimproved patient access to care appear.The nature of advanced
practice is broader than individual roles or functions.
Regulation of the Advanced Practice
Registered Nurse
Regulation of APRNs occurs at the state level, but there
are both educational and certification prerequisites.
Graduate-leveleducational preparation of APRNs is guided
by educators and members of professional organizations
who identify essential curricular goals, content, and
competencies expected of APRN graduates. In 2004, the
American Association of Colleges of Nursing (AACN) called
for doctoral-level preparation as entry level for APRNs,
with a proposed implementation date of 2015. However,
several barriers to moving entry-level practice preparation
to the doctoral level have been identified. These barriers
include financial costs, limited faculty resources, the need
to obtain permissions from numerous levels of leadership,
boards and regulatory bodies, finding clinical sites, and
more (Rand Corporation, 2010). Many schools of nursing
moved their APRN education to the doctoral level, with
most offering the doctorate of nursing practice (DNP)
degree; however, only the American Association of Nurse
Anesthetists (AANA) has mandated that as of 2022, all
graduates of educational programs must be prepared at the
doctoral level for entry into practice (AANA, 2010). The
remaining APRN groups have not embraced mandating
doctoral education for entry into practice.
Content and competencies core to all APRNs and
those specific to a particular role must be provided in
all APRN educational programs. Table 2.2 lists major
APRN organizations that develop the educational and
certification prerequisites and the APRN essential content
and competency documents that direct the preparation
of APRNs for entry into practice. On completion of an
accredited masters or doctoral-level program, graduates
generally must pass a national certification examination in
the area of intended practice before applying for licensure
at the state level.
APRNs may be recognized and licensed at the state level
in one of the four aforementioned roles. However, many
issues have been identified with the current regulatory
process, particularly eligibility for reciprocity of licensure
between states. In response to this need to develop more
consistent standards for APRN recognition across states, the
APRN Consensus Work Group and the National Council
of State Boards of Nursing have developed the Consensus
Model for APRN Regulation: Licensure, Accreditation,
Certification and Education (Consensus Model, 2008).
This document has been accepted by numerous nursing
organizations and stakeholder groups. The regulatory
model acknowledges the four APRN roles and recommends that advanced practice registered nursing must be

Chapter 2 Emerging Roles of the Advanced Practice Nurse 19
Table 2.2
Professional Organizations and Essential Educational Content
Organization Landmark Publications
American Association of Colleges of Nursing The essentials of masters education in nursing. Washington, DC: Author, 2011.
The essentials of doctoral education for advanced nursing practice. Washington,
DC: Author, 2006.
American College of Nurse-Midwives Core competencies for basic midwifery practice. Silver Spring, MD: Author, 2012.
Competencies for masters level midwifery education. Silver Spring,
MD: Author, 2014.
The practice doctorate in midwifery. Silver Spring, MD: Author, 2011.
American Association of Womens Health, Obstetric
and Neonatal Nurses, and National Association of
Nurse Practitioners Womens Health
The womens health nurse practitioner: Guidelines for practice and education
(7th ed.). Washington, DC: Author, 2014.
Council on Accreditation of Nurse Anesthesia
Educational Programs
Standards for accreditation of nurse anesthesia educational programs.
Chicago, IL: Author, 2016.
National Association of Clinical Nurse Specialists Criteria for the evaluation of clinical nurse specialist
masters, practice doctorate, and post-graduate certificate
educational programs. Philadelphia, PA: Author, 2012.
Organizing framework and CNS core competencies. Philadelphia,
PA: Author, 2008.
National Organization of Nurse Practitioner
NP core competencies with curriculum content. Washington, DC: Author, 2014.
Adult-gerontological acute care nurse practitioner competencies.
Washington, DC: Author, 2012.
Adult-gerontological primary care nurse practitioner competencies.
Washington, DC: Author, 2010.
Population-focused nurse practitioner competencies: Family/Across the lifespan,
neonatal, pediatric acute care, pediatric primary care, psychiatric-mental
health, womens health/gender-related. Washington, DC: Author, 2013.
regulated in one of the four roles and in at least one of
six population foci: psychiatric or mental health, womens health/gender-related, adult-gerontology, pediatrics,
neonatal, and individual families across the life span. The
adult-gerontology and pediatrics populations are further
distinguished by either an acute care or a primary care
focus. Of note, the CNS practice is described to occur
across primary and acute care settings and as such must
be reflected in their education.
Requirements for consistent educational preparation
across all APRN roles have provided greater uniformity.
Content for all APRNs must include graduate-level courses
in advanced pathophysiology, advanced physical assessment, and advanced pharmacology, called the APRN core
(Consensus Model, 2008). In addition, content related
to the population served, role development, and clinical
experience in the specific role is required. The recommendations of the Consensus Model have and will continue
to influence the licensure, accreditation, certification, and
educational preparation of all future APRNs, and can be
found in Table 2.3.
Clinical Nurse Specialist
CNSs are nurses with masters- or doctorate-leveleducation
in a defined area of knowledge and practice. They typically
work in unit- or population-based settings; in hospitals,
offices, or outpatient clinic settings; and in community
practice. In an analysis of acute care advanced practice
nurses performed by the American Association of Critical

20 Unit 1 The Evolution of Advanced Practice
The CNS shifts functions depending on the needs
of the situation and participates in a mix of direct and
indirect patient care activities. Still, the traditional roles
of CNS practice remain, including those of expert practitioner, educator, consultant, manager, and researcher.
See Boxes 2.1 and 2.2.
The Clinical Nurse Specialist and Cost Savings
Multiple studies have demonstrated the positive contributions of CNSs to patient care outcomes and patient
satisfaction, but fewer studies have evaluated their economic impact and their ability to generate income and save
costs. A recent study by Richardson and Tjoelker (2012)
demonstrated a CNS-led initiative to decrease central line
associated bloodstream infections (CLABSI), saving the
organization $214,712 in terms of cost avoidance and
1.4 lives saved out of 8 patients with CLABSI. Similarly,
Maze and Riggins (2011) demonstrated a CNS-led initiative resulting in the CLABSI rate to be consistently
below the National Healthcare Safety Network (NHSN)
benchmark. These savings are real, but they may not be
returned to the CNSs home (usually nursing) department.
Because of this, the immediate supervisors of CNSs may
not appreciate the benefits of expert CNS practice. This
reality is compounded by the inability of CNSs to bill
directly for services if they are hospital-based, salaried
employees. Skilled advanced practice nursing care is not
directly reimbursed and remains bundled in the hospitals
Care Nurses (Becker et al, 2006), CNSs were asked to
rate activities they perform that are most critical to their
practices. Activities selected included the following:
Synthesizing, interpreting, making decisions and recommendations, and evaluating responses on the basis
of complex, sometimes conflicting, sources of data
Identifying and prioritizing clinical problems on the
basis ofeducation, research, and experiential knowledge
Facilitating development of clinical judgment in
health-care team members (e.g., nursing staff, medical
staff, other health-care providers) through serving as
a role model, teaching, coaching, and/or mentoring
Promoting a caring and supportive environment
Promoting the value of lifelong learning and evidence-based
practice while continually acquiring knowledge and
skills needed to address questions arising in practice
to improve patients care
Evaluating current and innovative practices in patients
care on the basis of evidence-based practice, research,
and experiential knowledge
Incorporating evidence-based practice guidelines, research,
and experiential knowledgeto formulate,evaluate, and/
or revise policies, procedures, and protocols.
Theseresults demonstrated the performance of activities
that at one time were performed solely by physicians and
currently also overlap with those performed by acute care
nurse practitioners (ACNPs).
Table 2.3
Essential Characteristics of the Advanced Practice Registered Nurse*
1. Completion of an accredited graduate-level program in one of four areas: nurse-midwifery, nurse anesthesia, NP, or CNS
2. Successful completion of a national certification examination measuring APRN role and population of focus competencies and
maintains competence through recertification
3. Possession of advanced clinical knowledge and skills needed for direct patient care, and a significant component of education
and practice focuses on direct care of individuals
4. Practice builds on RN competencies and demonstrates depth and breadth of knowledge, data synthesis, complex skills,
intervention, and role autonomy
5. Educational preparation for health promotion and maintenance, assessment, diagnosis, and management of patient problems
including use and prescription of pharmacological and nonpharmacological interventions
6. Possesses depth and breadth of clinical experience reflecting intended area of practice
7. Possesses license to practice as an RN, and then further as a CRNA, CNM, CNS, or CNP
APRN, advanced practice registered nurse; CNM, certified nurse-midwife; CNP, certified nurse practitioner; CNS, clinical nurse specialist; CRNA, certified
registered nurse anesthetist; RN, registered nurse.
*Adapted from Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. (2008). Completed through the work of the
APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee.

Chapter 2 Emerging Roles of the Advanced Practice Nurse 21
Margo is an adult critical care CNS who is masters
prepared and has been working in a large academic
health system for more than 6 years. Margo works on a
neurosurgery step-down unit where her clientele ranges
from patients with seizure disorders, those recovering
from major strokes or traumatic brain injuries, and a
host of neurosurgical conditions. She is a key member
of the health-care team,especially because of her wealth
of knowledge and experience with neurologically impaired patients. Margo leads interdisciplinary rounds
that include attending physicians, fellows and residents
in training, nurses, APRNs, pharmacists, dietitians,
and physiatrists. She empowers her nursing staff to
actively participate in rounds and provides them the
resources and encouragement they need to have their
voices heard. Margo is instrumental in assuring that
the patients on her unit are receiving high-quality and
safe care. Recently her unit was recognized for having
met or exceeded quality metrics for 6 months in a row.
Margo currently leads the CNS Leadership Group in
her hospital. This group meets monthly to network with
the 30+ CNSs that work throughout the system. This
group sets internal standards for clinical and professional
activities, reviews initiatives, and provides support to
CNSs who often work in silos caring for their specific
patient populations.
Box 2.1
The Unit-Based Clinical Nurse Specialist Profile
Sue is a nurse who has doctoral-level training and has
been a CNS for the past 20 years. She began her CNS
career in a major teaching hospital during which she
worked on the writing group to help the organization
to achieve Magnet status. She also developed a postcardiothoracic surgery glycemic protocol, an orientation
for BSN-prepared nurses and CNSs, along with many
other significant initiatives. Subsequently, she was hired
by a corporation as a consultant for all their ICUs. In
this role, she helped to establish standards of care, has
served as chair of numerous committees, developed
protocols for safe handoffs, and worked with the interdisciplinary team to address quality and core measures.
The significant travel requirement is a challenge, but
she is pleased to know that her expertise has had such a
significant impact across many organizations, resulting
in a positive impact on the interdisciplinary team and
the patients that they serve.
Box 2.2
Corporate Clinical Nurse Specialist Profile
room, food, laundry, and supplies bill. More creative and
appropriate financial models that could remedy thesituation
are needed. This limitation on role functioning is usually
not faced by self-employed or practice-based CNSs, who
likely are not institutional employees and generally work
in outpatient or community settings.
One recent randomized controlled trial identified that
cost savings were achieved, without loss of quality, by
substituting physicians with diabetes nurse specialists in
caring for patients with diabetes (Arts, Landewe-Cleuren,
Schaper, & Vrijhoef, 2012). Few studies comparing CNS
care to physicians exist primarily because of most CNSs
working in hospitals. However, the CNS can play a key
role in providing care to underserved populations and
should be considered instrumental in achieving the goals
of the ACA.
The Clinical Nurse Specialist and Evidence-Based
Practice (EBP)
CNSs have long been considered change agents; recently,
the implementation of EBP is where many CNSs spend
their time. However, several barriers to implementing

22 Unit 1 The Evolution of Advanced Practice
framework, the CNS is expected to provide continuous
and comprehensive care to improve outcomes for acutely
and critically ill patients. This is done in a collaborative
model that includes patients, families, significant others,
nurses, and other providers and administrators (Bell &
McNamara, 2010).
A contribution of this document is that it sets goals and
standards for CNS practice and contributes to further role
clarification for hospital-based CNSs. The values identified
in this document for continuous and comprehensive carefor
acutely and critically ill patients suggest that thescope of the
critical care CNSs responsibilities are not limited to acute
or special care units. Seriously ill patients arefound in most
hospital units, and their continuing specialized care needs
are now frequently required in nonhospital or outpatient
settings. It is likely that postdischarge role functions will
become more common for the acute or critical care CNS.
The publishing of CNS Core Competencies by the
National CNS Competency Task Force (Clinical Nurse
Specialist Core Competencies, 2010) also attempts to reduce
role ambiguity for the CNS. This task force identified the
various roles and activities of CNSs in numerous practice settings and validated them by surveying more than
2,000 CNSs. The range of agreement was 90% to 98%.
These competencies will aid educators, employers, and
new CNSs in understanding their role and responsibilities
as well as their contributions to patient care outcomes.
However, CNSs have not obtained the clarity they
are seeking. Recently, the Office of Management and
Budgets Standard Occupational Classification (SOC)
Policy Committee inaccurately designated CNSs as general
registered nurses instead of APRNs. This miscategorization
will result in the inability of researchers to capture accurate
data and statistics as they relate to the CNS workforce,
further reducing the importance of the CNS role to the
health care of U.S. citizens (NACNS news release, 2016).
Nurse Practitioner
NPs are frontline health-care providers essential to
developing and maintaining successful communication
and collaboration among providers across health-care
settings. In both primary and urgent care settings, NPs
can ensure continuity of care, decrease health-care costs,
and optimize health outcomes for patients (Villasenor &
Krouse, 2016).
changeexist in clinical settings such as reluctance to change
approaches when the old way still works. A recent study
by Campbell and Profetto-McGrath (2013) identified
five challenges to implementing EBP by CNSs: time
constraints for the CNS, time constraints for the bedside
nurses, multiple roles of the CNS reducing dedicated time
to focus on EBP implementation, heavy workload and
lack of resources, and both individual and organization
support (Campbell & Profetto-McGrath, 2013).
However, when CNSs are provided thetime and resources
to perform their role, positive outcomes occur. Recently, CNS
involvement in quality initiatives and their contributions to
improved patient outcomes has been recognized as agencies
apply for Magnet Recognition. The Magnet Recognition
Program offered by the American Nurses Credentialing
Center (ANCC) recognizes health-care organizations for
quality patient care, nursing excellence, and innovations
in professional nursing practice (ANCC, 2011). The
CNS role is essential to implementing innovation and
sustaining improved patient outcomes, which are integral
components of the Magnet Recognition Program (Muller,
Hujcs, Dubendorf, & Harrington, 2010). The CNS role
broadly and specifically supports the process by which
care is delineated, changes are made, and improvements
are noted. CNS participation in the attainment of these
goals and the movement of organizations toward achieving Magnet status likely will provide new and expanded
opportunities for the CNS.
Ambiguity and the Clinical Nurse Specialist Role
The observation that CNS practice reflects role ambiguity
undoubtedly grows out of the ability of the CNS to adapt to
changing patient, family, and nursing staff needs, supported
by a broad clinical repertoire of skills and knowledge. This
adaptability provides role confusion not only for those
implementing the role, but also for those observing it.
There have been several responses to the problem of role
ambiguity with in-hospital CNS roles. One has been the
development of AACNs Scope and Standards for Acute
and Critical Care Clinical Nurse Specialist Practice(Bell &
McNamara, 2010). This document provides guidelines for
competent and professional carefor acutely and critically ill
patients. It also reflects thethree spheres of CNS influence:
patient and family, nursing personnel and other health-care
providers, and the organizational system for care delivery in
different settings (Bell & McNamara, 2010). Within this

Chapter 2 Emerging Roles of the Advanced Practice Nurse 23
in which the center is located; and to provide a means of
improving the quality of the care delivered (Zachariah &
Lundeen, 1997).
Building on the concept of nurse-run clinics, the
National Committee for Quality Assurance (NCQA),
a prominent health-care quality organization, reports
that it will recognize nurse-led primary care practices
as patient-centered medical homes under the Physician
Practice ConnectionsPatient-Centered Medical Home
recognition program (Schram, 2010). In this program,
practices are encouraged to add names of eligible NPs to
their practice information. The medical home concept
was developed to reward providers for the coordination
and management of patient-centered care of individuals
with complex and multiple chronic illnesses, activities that
NPs can easily perform. What is uncertain is whether NPs
were actually included in the staffing of Medical Homes.
In a study conducted in New York (NY) State, Park (2015)
compared the number of NPs and physician assistants
(PAs) to primary care physicians in both designated and
undesignated PCMHs. She found a significant increase
in the number of NPs and PAs relative to Primary Care
Physicians in designated PCMHs. This is a promising
result, but only reflects the current condition in NY State.
Pediatric Nurse Practitioners
Societal changes also affect the care of children. Child abuse
continues to be one of the nations most serious concerns.
During 2012, 3.4 million referrals for child abuse were
made in the United States, involving 6.3 million children
and resulting in 1,640 deaths (CDC, 2014c). Childhood
immunization is also a top health priority in the United
States. More than 600 cases of measles were reported in
2014, a disease thought to have been eradicated in the
United States in 2000 (CDC, 2014b).
Recent reports show serious issues with childhood
obesity, bullying, and increases in suicide attempts in adolescents aged 10 to 14 years (CDC, 2014a). The need for
appropriately prepared pediatric NPs is urgent. However,
few U.S. nurses gravitate toward pediatrics or the NP
role. So, although the role is not new, the opportunities
for nurses to care for our nations children are abundant.
Nurse Practitioners in Transitional Care Settings
Hospital-based nurses have traditionally focused their
interventions on preparing patients for discharge from
The educational preparation of NPs has moved from
continuing education programs offering certification
on completion to university-based graduate programs
granting a masters or doctorate degree in nursing.Today,
NPs are the largest group of APRNs and have prescriptive
authority in all 50 states and the District of Columbia
(Phillips, 2016). APRNs assess and manage both medical
and nursing problems and serve as both primary and acute
care providers.
Changing Roles for the Primary
Care Nurse Practitioner
Initially, patient populations cared for by NPs were often
uninsured immigrants or low-income individuals who
were Medicaid recipients. However, NPs since have sought
to meet the needs of larger groups of patients and have
expanded their practices to include clients from suburban
and urban outpatient settings and clinics. This shift to highly
populated, high-income areas where physicians are also
readily available shows the increased acceptance of NPs.
Retail and Urgent Care Clinics
The development of walk-in, retail, and urgent care clinics
has changed the landscape for accessing primary care services. These clinics are major employers of NPs and thus
provide an opportunity to showcase to the public some of
the care that NPs can provide. According to the National
Conference of State Legislatures (NCSL) website, as of 2015,
2,000 retail clinics operate in 41 states and Washington,
DC (NCSL, 2015). Recognizing the potential impact of
these clinics on the APRNs, the American Academy of
Nurse Practitioners (AANP) published Standards for Nurse
Practitioner Practice in Retail-Based Clinics (AANP, 2007).
Nurse Practitioners in the Community
Primary care NPs haveestablished unique community-centered
practice models. In an effort to develop an independent
NP service model and to study the ways health care is
delivered to various populations in the United States, many
schools of nursing opened Academic Community Nursing
Centers (Naylor & Kurtzman, 2010; Oros, Johantgen,
Antol, Heller, & Ravella, 2001). These centers are used
as settings in which to study how health care is provided
to vulnerable populations with limited access to care, who
face inefficiencies and a lack of coordination in health-care
delivery; to determine the specific needs of the community

24 Unit 1 The Evolution of Advanced Practice
The Psychiatric and Mental Health
Nurse Practitioner
In the 1950s, the APRN role of the psychiatric and
mental health nurse was conceptualized as a CNS role.
With developments in the science underpinning mental
health and psychiatric illnesses, emphasis shifted from a
traditional psychosocial approach to care to a biopsychosocial paradigm. In the latter model, psychopharmacology
assumed a prominent place in the treatment inventory.
Acceptance of this movement was demonstrated by the
development of national certification examinations for
the psychiatric and mental health NP. Initially, there were
two examinations availableadult and family (American
Nurses Credentialing Center [ANCC], 2016). With the
adoption of the Consensus Model (2008), the psychiatric
and mental health APRN shifted to a focus on the individual across the life span. Prescriptive authority is available
in 40 states for both CNSs and NPs (NACNS, 2015).
However, NPs have prescriptive authority in all 50 states.
For this reason, the psychiatric and mental health NP has
become the only educational preparation for this APRN
role. See Box 2.3.
A newly designed role for the psychiatric mental
health NP is being developed through the University of
Nebraska Medical Center College of Nursing (UNMC
CON). Recognizing the needs of our citizens for both
primary care and mental health services, UNMC CON
has proposed a new program for an integrated family nurse
practitioner/psychiatricmental health nurse practitioner
(Hulme, Houfek, Fiandt, Barron, & Mulhbauer, 2015).
It is anticipated that this provider will care for patients
across the mindbody spectrum in integrated mental
healthprimary care positions. Opportunities for APRN
educational innovations will continue to emerge as nurses
continue to respond to societal needs.
Womens Health/Gender-Related
Nurse Practitioners
The womens health/gender-related NP role grew out of
identification of the unique needs of women and initially
focused on family planning, infertility, sexual dysfunction, gynecological care, perimenopausal issues, and the
diagnosis and treatment of sexually transmitted infections
(STIs) throughout the life span. Because of low income
and the lack of resources available to many women, the
role expanded to include well-woman health with a focus
the hospital. However, the time for providing discharge
teaching and answering patient and family questions
is limited and often results in patients returning to the
hospital because they did not completely understand their
discharge instructions.
If patients were lucky enough to have a home health
nurse visit them when they were discharged, these nurses
often identified problems and concerns regarding the
health of their patients and have had to contact the patients physician to determine the next course of action,
a step that often caused a delay in treatment. Therefore,
the need for APRNs who can provide transitional care
from hospital to community became particularly evident.
Several viable models of APRNs in transitional roles have
been demonstrated through research efforts (Blewett et al,
2010; Hirschman & Bixby, 2014; Naylor et al, 2000). The
clearly demonstrated, favorable patient-centered outcomes
of Naylors Transitional Care Model (2000) have gained
significant recognition to the point of being named in
the ACA as an example of a program showing substantial
contributions to reducing health-care costs. However, there
is still a need to further develop reimbursement systems
for the services of APRNs.
Nurse Practitioners as Consultants
in the Community
The NP as consultant in community health settings is
another emerging advanced practice role. Long-term care
facilities, nursing homes, and rehabilitation centers aresettings that havefew APRNs or professional nurses. However,
residents in these settings often have chronic health needs
that go untreated or unnoticed until they becomeserious.
In response, some administrators have developed roles for
APRNs to address health issues more quickly (Neal-Boylan,
Mager, & Wallace-Kazer, 2012). More APRNs can be
found in rehabilitation centers, inpatient hospice, skilled
nursing facilities, and other nontraditional health-care
settings. These community-based APRNs assess problems
and develop plans of carein an attempt to prevent further
progression of symptoms or needless suffering. Restrictions
on APRNs ability to function independently may limit
the range of services they can provide. In addition, there
are restrictions on the type of services for which APRNs
can bill directly. However, as changes in health-care reimbursement policies continue to occur, the consultant role
in the community will grow more popular.

Chapter 2 Emerging Roles of the Advanced Practice Nurse 25
Rochelle is an adult ACNP working in palliative care
in a university hospital. In her role, she is a member of
the multidisciplinary team that includes several NPs, a
pharmacist, collaborating physicians, fellows, a chaplain, a social worker, and an art and music therapist.
Her role is solely inpatient, Monday through Friday,
during daytime hours. She serves as a consultant for
patients facing serious and often life-threatening illness to provide support in making care decisions and
managing diverse symptoms with a significant focus
on pain management. Billing is done under her NPI
or the collaborating physicians.
Rochelleenjoys being ableto tap into the expertise of
her diverse team. Because she is in a university hospital,
she has the opportunity to participate in daily huddles,
a weekly conference including expert guest lecturers,
team member presentations, journal club, and case
presentations. She also feels her patients benefit from
the strong collaboration of the palliative team with
nursing, attending physicians, hospital social workers,
and case managers.
This role is a great fit for her; however, it is very
different than her former colleagues role in a rural
setting across the country. Amelia joined a private
practice in which she has the dual role of both palliative
care and hospice NP and is the only provider of these
services for the entire community. Her role includes
seeing patients in the office, rounding in the hospital,
making home hospice visits, and handling on-call
responsibilities for evenings and weekends. Although
she sometimes feels isolated and often misses the daily
peer collaboration, educational, and other benefits of
working in a university environment, she enjoys the
intensive continuity of care that she can provide her
patients in multiple settings. In her practice, she bills
for all her services.
Box 2.3
Adult Acute Care Nurse Practitioner in Palliative Care Profile
on holistic care, prevention and healthy lifestyles, mental
health issues, and identification of issues such as partner
violence. The womens health NP also focuses on common
urological problems such as incontinence and cystitis, and
performs procedures such as cystoscopy, circumcision,
intrauterine device (IUD) insertion, endometrial biopsy,
and obstetrical ultrasonography.
Over the years, these experts recognized a lack of providers to address mens sexual and reproductive health needs.
Thus, the education and role of the womens health NP
expanded to include the diagnosis of, screening for, and
evaluation and management of mens issues such as STIs
and fertility issues. In recognition of the effectiveness of
these womens health practitioners, the Consensus Model
(2008) calls for womens health practitioners to expand
their population focus. The formal recognition of care to
men will undoubtedly provide for future expansion of the
role. Additionally, womens health NPs have increased their
focus on the need of the aging woman. AACN has developed specific competencies to address the special needs of
this population; these include issues such as assessing falls
risk, recognizing the impact of sensory deficits, assisting
with transitions of care, and advocating for the special
needs of the older adult (AACN, 2010).
The National Association of Nurse Practitioners in
Womens Health (NPWH) has demonstrated its leadership and commitment to health policy by partnering with
the American Academy of Family Physicians (AAFP), the
American College of Physicians (ACP), and the American
College of Obstetricians and Gynecologists (ACOG) to update
the Womens Preventive Service Guidelines (HRSA, 2016).
Womens health NPs have recently expanded into general primary care practices that need a clinician to focus
on womens health issues. They have also expanded their
role in specialty problem areas such as incontinence care,
sexuality, and caregivers support as most often women in
the family assume the role of transitioning parents into
elder care after or sometimes during the time they are
raising their families (Wysocki, 2014).
Acute Care Nurse Practitioner
NPs are found not only in primary care but also in
specialized areas such as neonatal, pediatric, geriatric,
and acute and critical care settings. The term acute has

26 Unit 1 The Evolution of Advanced Practice
Neonatal Nurse Practitioner
The neonatal NP (NNP) roleis a collaborative one. Several
studies have examined the quality of outcomes of care
delivered by neonatal NPs compared with that delivered
by medical housestaff. Results demonstrated that care delivered by NPs was as good as or better than that delivered
by housestaff on measures of cost-effectiveness and quality.
In addition, care delivered by neonatal NPs had greater
continuity and consistency (Bissinger, Allred, Arford, &
Bellig, 1997; Mitchell-DiCenso et al, 1996).
The supply of NNPs has rarely met the national demand for services. Consistent shortages of NNPs leave a
significant gap in the team approach to care (Kaminski,
Meier, & Staebler, 2015). However, the care NNPs provide
is often viewed to be so specialized that few nurses seek
to fulfill this role (Bellini, 2014). This shortage of NNPs
is anticipated to worsen. In addition, the Accreditation
Council for Graduate Medical Education (ACGME) proposes to reduce the required number of neonatal intensive
care unit (NICU) hours pediatric residents must complete.
This is especially concerning with an inherent shortage of
providers, as it is thought that individuals who become
neonatal providers are those who have trained and worked
in the collaborative environment of the NICU. However,
this does provide opportunities for NNPs to fill the gap.
The Pediatric Acute Care Nurse Practitioner
The pediatric ACNP was a relatively late arriver to the NP
workforce. This was due in part to the strong role held
always been associated with the type of facility in which
patient care is provided, but it is also used to describe
the patient who is experiencing either a new onset or
an exacerbation between an existing illness and those
patients who have complex chronic illnesses that teeter
on the edge of wellness and illness (Bell, 2012). Thus,
ACNPs are no longer defined by the geographical setting
in which they provide care but by the patient population
they serve. ACNPs provide care in a variety of settings
such as hospitals, intensive care units (ICUs), long-term
acute care hospitals, outpatient and inpatient hospices,
specialty offices, and operating rooms. They may be practice
based, such as those working on a cardiothoracic service,
or unit based, such as those working in a medical ICU or
cardiac step-down unit. They may also be on teams that
provide care across settings such as those in hospitalist
positions or on consultative teams such as acute diabetes
management services (see Box 2.4).
A new leadership rolethat hasemerged is director of NPs
or advanced practice providers. This role has improved the
work environment for NPs who had previously reported
to office managers or physicians. The director of NPs is
familiar with issues regarding scope of practice, licensure,
and certification. He or she can serve as an advocate as
well as a mentor for professional development projects
such as publications and presentations (DAgostino &
Halpern, 2010). These new practice areas demonstrate
the diversity of practice opportunities available to meet
the needs of acutely ill patients.
Anya is a psychiatric mental health NP who is prepared at the masters level and for the past 5 years has
worked with a private oncology practice supporting
clients with multiple psychological problems. Her
clients include late adolescents and adults undergoing
cancer treatment. She is a critical member of the team,
especially because she manages psychological issues
that can get in the way of treatment decisions, disease
management, and patient follow-through. She is also
recognized by the palliative care team as a consultant
and expert clinician in managing psychological issues
in those facing life-threatening diseases. Although she
sees clients of her own, she has helped the oncology and
palliative care MD and NP providers manageissues such
as depression and identify when they should consult a
psychiatric mental health professional for particularly
challenging cases. Although she is very satisfied with
her work, she is frustrated by state requirements such as
the need for a collaborating physician and limitations
on her ability to prescribe certain medications.
Box 2.4
Psychiatric Mental Health Nurse Practitioner Profile

Chapter 2 Emerging Roles of the Advanced Practice Nurse 27
had to change their examinations to cover the breadth of
knowledge required to implement the role.
Similar to the roles of their pediatric counterparts,
the roles of adult-gerontology ACNPs (AGACNPs) are
evolving and expanding throughout the acute care setting.
AGACNPs are found in traditional care settings such as
emergency rooms, ICUs, step-down or progressive care
units, and medical-surgical floors. Adult gerontology
ACNPs also deliver care to patients outside the tertiary or
quaternary care institutions in settings such as outpatient
surgical centers, centers for the management of mechanically ventilated patients, long-term acute care hospitals,
psychiatric evaluation centers, dialysis units, heart failure
centers, and correctional facilities.
In the Kleinpell and Goolsby (2012) study of ACNP
practice as part of the larger 20092010 National NP
Sample Survey, ACNP respondents continued to develop
new roles to fulfill identified needs for APRNs to manage
aspects of patient care in a variety of settings. NPs were
found to be practicing in specialty care areas such as the
cardiology, pulmonary, and specialized neurology settings;
hematology and oncology; specialty ear-nose-throat (ENT)
services; a variety of surgery services; palliative care; pain
management services; and others. New areas of practice for
ACNPs were hospitalist roles, palliative care, and roles in
physician private practices (Kleinpell & Goolsby, 2012).
Adult Gerontology Acute Care Nurse
Practitioners in Specialty Practices
In tertiary health-care centers, further reductions in medical
resident work hours have contributed to fragmented care
and a shortage of providers. The AGACNP can provide
much-needed stability and continuity, which is known
to produce positive patient outcomes. Complex settings,
where continuous follow-up of patients is necessary, are
ideal practice areas for AGACNPs. AGACNPs can make
a positive impact on the health-care delivery system by
providing a continuous and comprehensive approach to
the management of their patients needs.
Acute Care Nurse Practitioners in Oncology
Oncology is one specialty area in which NP expertise for
continuous and comprehensive care is crucial. Oncology
settings span the cancer trajectory from high-risk cancer
clinics to hospice and palliative care (Vogel, 2010;
Volker & Limerick, 2007). NPs in oncology bring a
by CNSs in pediatric settings. When the role of ACNP
first started, it was a blended role of the CNS and NP in
an attempt to provide comprehensive services and direct
patient careto pediatric patients and their families. Now the
APRN roles in pediatric acute care are distinctly separate.
With implementation of the Consensus Model (2008),
CNSs and NPs must be certified distinctly in one of these
roles based on theireducational preparation and eligibility for
licensurein thestatethey practice.The many responsibilities of
the APRN in pediatrics includesuch activities as performing
health histories and physicalexaminations;evaluating clinical
data; prescribing treatments; performing invasive procedures,
such as tracheal intubation and insertion of arterial lines;
educating and supporting patients and families; facilitating
patient discharge; participating in interdisciplinary rounds;
and providing consultative services regarding such issues
as wound care and infant feeding problems (Reuter-Rice,
Madden, Gutknecht, & Foerster, 2016).
The pediatric ACNP can be found on specific patient
care units such as the medical-surgical floor or the ICU;
function in the hospitalist role; or be a member of a specialty service such as cardiology, pulmonary, oncology,
transplantation, gastrointestinal, and general surgery
(Reuter-Rice, Madden, Gutknecht, & Foerster, 2016).
Pediatric ACNPs may also work outsidethe hospital setting
in other areas in which acutely ill pediatric patients are
found. Such areas include long-term acute care centers,
centers for the management of mechanically ventilated
patients, transport services, and homesettings (Reuter-Rice,
Madden, Gutknecht, & Foerster, 2016).
The role that each NP assumes depends largely on the
specific needs of the patients cared for.Thefocus of therole,
regardless of the geographical location in which the pediatric
ACNP works, is to provide cost-effective and high-quality
patient care.
Adult Gerontology Acute Care Nurse Practitioners
Acknowledging the aging of the American public and the
need to properly train providers who can meet the multifaceted needs of older adults, the crafters of the Consensus
Model (2008) explicitly changed the population focus of
adult care NPs to adult gerontology. With this significant
emphasis on the needs of older adults, educational programs had to revise their curricula to clearly address the
competency requirements of the adult gerontology patient
across the adult age continuum and certifying bodies

28 Unit 1 The Evolution of Advanced Practice
Nurse-midwifery is recognized in all 50 states, although
it is regulated by various agencies in the different states and
has varying scopes of practice from state to state. The main
scope of practice issue has to do with independent versus
collaborative practice with physicians. Physician practices
(21.7%) and hospitals (29.5%) continue to be identified
as the primary employers of nurse-midwives (Schuiling,
Sipe, & Fullerton, 2013). For nurse-midwives practicing
in hospital settings, clinical privileges may be granted
through membership in the medical staff or through other
privileging routes. The purpose of requiring institutional
credentialing and practice privileges is to ensure that
nurse-midwives provide patient care within the parameters
of professional practice that are consistent with national
standards and state regulations (ACNM, 2006).
Although nurse-midwives practice predominantly in
hospitals and physician-owned practices, they also practice
in educational institutions, midwife-owned practices,
community health centers, nonprofit health agencies, military or federal government agencies, and birthing centers
(Schuiling et al, 2013). Nurse-midwives have advocated
for women for years. An exciting initiative started by
the American College of Nurse-Midwives in 2015 is the
Healthy Birth Initiative: Reducing Primary Cesareans Project
The goal of this project is to set up care bundles in birthing centers and hospitals that proactively work with the
laboring woman in such a way that the experience does
not require the delivery of the baby via Cesarean section.
A recent consequence of nurse-midwives expanding
their practices and becoming entrepreneurial is the expansion of their duties into more administrative areas such
as budgeting, setting up and interpreting quality metrics,
taking on human resource responsibilities, scheduling, and
developing policies and procedures (Slager, 2016). As these
activities become more commonplace, the educational
preparation for nurse-midwives may have to include these
content areas. See Box 2.5.
Primary Care Focus in Nurse-Midwifery
As nurse-midwives provided obstetrical care to women
throughout their childbearing years, they realized that
many women did not have access to primary care services. It became a natural progression for women to seek
their primary health-care needs from the health-care
provider they had trusted during their childbirths; thus,
unique holistic perspective that enables them to provide
expert care with issues such as pain management, symptom
palliation, and sensitivity to the psychological aspects of
a cancer diagnosis. NP roles in oncology are varied and
can include outpatient roles in radiation therapy, chemotherapy, surgical clinics (preoperative and postoperative
global care), palliative care, survivorship and prevention,
and genetic counseling related to cancer risk. These NPs
can also be found in ICUs as well as medical or surgical
oncology units. Because of the Consensus Model, there
are no longer stand-alone oncology NP programs. NPs
must be prepared as either primary care or ACNPs and
then can complete additional training and obtain specialty
certification in oncology. See Box 2.4.
In 2007, the American Society of Clinical Oncology
(ASCO) Workforce Study predicted a 48% increase in the
demand for medical oncology services by the year 2020.
This need far exceeds the number of medicine trainees
that will be available (Erikson et al, 2009).
Nurse-midwives are registered nurses who are primary
health-care providers to women throughout the life span.
They perform physical examinations; prescribe medications, including contraceptive methods; order laboratory
tests as needed; and provide prenatal care, gynecological
care, and labor and birth care, as well as health education
and counseling to women of all ages. Per the American
College of Nurse-Midwives (ACNM) position statement,
Mandatory Degree Requirements for Entry Into Midwifery
Practice, a graduate degree is required for entry into midwifery practice (ACNM, 2012b). All midwifery education
programs provide the necessary education for graduates to
be eligibleto takethe examination offered by the American
Midwifery Certification Board (AMCB) and become
CNMs. The Accreditation Commission for Midwifery
Education (ACME) (formerly the ACNM Division of
Accreditation [DOA]) assesses the quality and content
of midwifery education programs and ensures that they
reflect the ACNM core competencies.
The ACNM has mandated graduate-level education for
entry into midwifery clinical practice since 2010. In the
past masters programs predominated in nurse-midwifery
preparation, however, many programs have discontinued their
masters degree option and only offer a DNP (ACNM, 2012a).

Chapter 2 Emerging Roles of the Advanced Practice Nurse 29
education, and disease prevention and identifies women
as central in providing this care (ACNM, 2012c). CNMs
have also focused on the care of adolescent women, noting
that they are largely a medically underserved group. They
are recognized as a key component of the Patient Centered
Medical Home, also referred to as the Maternity Care
Home (ACNM, 2012b).
Nurse-Midwife as First Assistant
for Cesarean Section
Another role of the CNM that has grown is that of the surgical first assistant. Because of obstetrical residency programs
across the nation closing and cost containment resulting in
fewer physicians available to serve as first assistants, CNMs
have expanded their roles to fill the gap (Tharpe, 2015).
Additionally, because in many cases the CNM is already
present at the time of an emergency Cesarean section, a
delivery can progress without interruption, resulting in
better outcomes for both the mother and the newborn,
when the CNM is prepared as a surgical first assistant.
Not unexpectedly, there is opposition to this expansion of the CNM role. The Association for Perioperative
Registered Nurses (AORN) and some surgeons are not
convinced that CNMs possess adequate knowledge to
perform the first assistant role safely. In response to this
criticism, the ACNM (2016) has set guidelines for those
CNMs who wish to serve as a first assistant and defined the
role of the first assistant in Cesarean sections as a frequently
performed advanced midwifery skill requiring training and
supervision in patient assessment, anatomy and physiology,
principles of wound repair, and the development of basic
nurse-midwives began to provide care to perimenopausal
and postmenopausal women, a natural expansion of their
scope of practice. As the aging of U.S. Americans evolves
in the 21st century, the number of women approaching
menopause is growing. Large numbers of women are expected to seek menopausal and postmenopausal care from
nurse-midwives. In responseto this changein demographics
and the need for greater access to primary care providers,
CNMs have expanded their scope of practice to include
provision of primary care to women across the life span
from adolescence to beyond menopause, with a special
emphasis on pregnancy, childbirth, and gynecological and
reproductive health.
The scope of practice for CNMs also includes treatment
of male partners for sexually transmitted infections and
reproductive health and care of the normal newborn during
the first 28 days of life (ACNM, 2012c). Interestingly, this
scope of practice reflects the changes in the Consensus
Model: the population focus of midwives from womens
health to womens health/gender-related care. CNMs continue to focus on midwifery so as to not lose the essence
of nurse-midwifery practice, while acknowledging those
aspects of primary care that are part of the services offered
to patients and their families.
Issues Related to Primary Care Practice
CNMs provide primary and preventive care in clinics and
other outpatient settings. The ACNM calls for care delivered
by CNMs to include all essential factors of primary care
and case management. This focus on the ambulatory care
of women and newborns emphasizes health promotion,
Siji is the practice director of a busy obstetrical, gynecological, and midwifery care program that includes
nine midwives and five physicians. She is responsible
for the recruitment and evaluation of staff members
and serves as liaison to hospital administrators and to
the professional and lay community.
As she has progressed in herrole, she has assumed more
administrative responsibilities including managing the
practice budget, overseeing productivity, and creating a
vision forthefuture of the practice. She has had to learn the
intricacies ofreimbursement because her practice accepts
numerous health insurance plans, and she acknowledges
a steep learning curve. Because this practice is new, she
also oversees the development of marketing strategies,
new practice policies and procedures, and the collection
of quality measures. She finds it hard to balancethiswith
her clinical responsibilities, but she enjoys having the
opportunity to develop her administrative skills.
Box 2.5
Certified Nurse-Midwife Clinical Profile

30 Unit 1 The Evolution of Advanced Practice
The AANA serves as the guiding professional organization for CRNAs, setting the educational and certification
standards and promulgating a code of ethics for CRNAs
(AANA, 2005b), along with the scope of nurse anesthesia
practice (AANA, 2013a), standards of nurse anesthesia
practice (AANA, 2013b), and standards for office-based
anesthesia practice (AANA, 2015). Nurse anesthetist
students must enroll in schools accredited by the AANA,
and upon graduation they must successfully complete a
certification examination. As of August 2016, they must
also participate in mandatory Continued Professional
Certification (CPC) every 4 years (with a 2-year check-in)
through the National Board on Certification and Recertification of Nurse Anesthetists (NBCRNA) that includes
100 hours of accredited continuing education and core
modules. They must also take a recertification examination
every 8 years (NBCRNA, 2016).
In 1998, masters degree preparation was required for
beginning nurse anesthesia practice. Although the required
masters degree does not have to be in nursing, about 50%
of graduate CRNA programs are located within schools of
nursing (AANA, 2010). By 2022 the entry-into-practice
educational requirement will be at the doctoral level.
CRNAs face significant ongoing difficulties in establishing their practice prerogatives. They face considerable
pressures from anesthesiologists who have attempted
to limit their scope of practice by conceptualizing the
administration of anesthesia as the practice of medicine
(Shumway & Del Risco, 2000). In 1982, the American
Society of Anesthesiologists (ASA) introduced the concept of an anesthesia care team (ACT), a practice model
requiring that all anesthetics be given under the direction
of an anesthesiologist (Shumway & Del Risco, 2000).
Theserestrictiveefforts wereinadvertently fostered with
theintroduction of an insurancereimbursement regulation
policy by Medicare in 1982. This policy attempted to
reduce charges of fraud for anesthesia care by establishing
specific conditions that held anesthesiologists accountable
for services they claimed to perform when working with or
employing CRNAs (Shumway & Del Risco, 2000). The
Tax Equity and Fiscal Responsibility Act (TEFRA) regulations set specific conditions for reimbursable services that
seemed to require physician leadership for the delivery of
anesthesia as a standard of care. Later attempts to eliminate
the necessity for anesthesiologist supervision for Medicare
reimbursement of CRNA services resulted in an opt out
surgical skills such as aseptic technique and suturing. At
present,each stateis addressing therequirements for CNMs
who practice as first assistants. Although the number of
CNMfirst assistants has grown substantially, this skill
is not part of the Core Competencies for CNMs, and
therefore requires additional education.
More recently, midwives have added the use of obstetrical and gynecological ultrasound examinations to their
repertoire of skills (ACNM, 2012d). Ultrasound examinations may be performed in all trimesters of pregnancy
to obtain specific information: determining gestational
age, assessing fetal well-being, monitoring interval fetal
growth, and measuring maternal cervical length. ACNM
(2012d) recognizes the need for additional educational
content, credentialing, and privileging for midwives who
choose to incorporate this into their practices. ACNM is
not mandating this as a required skill for all midwives but
recognizes that ultrasound examinations may be a necessary
tool in meeting the needs of ones patients.
As the needs of childbearing women have changed
over the years, the practice and skills of the nurse-midwife
have expanded to meet them. This trend will continue as
additional needs are identified.
Nurse Anesthetist
CRNAs are anesthesia specialists with authority to practicein
all 50 states and the District of Columbia. They administer
all types of anesthesia and provide anesthesia-related care
in thefollowing categories: preanesthetic preparations and
evaluation; anesthesia induction, maintenance, and emergence; postanesthesia care; and perianesthetic and clinical
support functions (Department of Health and Human
Services [DHHS], Public Health Service[PHS] Division of
Acquisition Management, 1995). Chronic pain is a major
issuein the United States. Unfortunately, access to care can
belimited as pain management procedures, such asepidural
steroid injections, are regulated at the state level and thus
cannot be performed by all CRNAs (AANA, 2014).
Nurse anesthetists provide a significant amount of the
anesthesia given for surgical procedures in the United
States. These APRNs work in urban and rural settings, and
provide more than 50% of the anesthesia administered in
rural areas (RAND Corporation, 2010). In contrast to the
high numbers of women in the other APRN categories,
41% of CRNAs are men (Rand Corporation, 2010).

Chapter 2 Emerging Roles of the Advanced Practice Nurse 31
Finally, 91% of ACT-based anesthetists in this sample were
employees compared with 4% who were self-employed,
whereas 49% of nonACT-based anesthetists were employees compared with 43% who were self-employed
(Shumway & Del Risco, 2000). See Box 2.6.
An Emerging practice area
for all advancedpractice registered
As the number of individuals in the United States with
life-limiting and serious illnesses increases, there is a need
to increase palliative care services that can help to improve
access and quality of life, increase patient and family satisfaction, and contain costs. In 2014, the authors of the
IOMs report, Dying in America: Improving Quality and
Honoring Individual Preferences Near the End of Life, made
recommendations that included an increase in access to
care for our aging population (Meghani & Hinds, 2015).
In 2010, the American Academy of Hospice and Palliative
Medicine published a workforce study that demonstrated
the need for up to 18,000 physicians in hospice and palliative care (Lupu, 2016).
APRNs have stepped up to try to fill the need in this
growing area. Palliative care APRNs can be found across
settings including inpatient, outpatient, skilled nursing
and rehabilitation facilities, and in the home. Although
one typically thinks of these specialists working in Primary
option for states (AANA, 2005a). Thiseffort has given way
to the current movement for APRN independent practice.
CRNAs quest for independent practice is a result of the
Consensus Model (2008). According to,
CRNAs currently have the ability to provide anesthesia
without physician supervision in 27 states (NCSBN, 2016).
One result of the struggle for CRNA practice prerogatives and leadership has been the establishment of
the ACT as the predominant practice model. To clarify
whether differences exist between CRNAs who work in
ACTs and those who do not, Shumway and Del Risco
(2000) evaluated personal and professional characteristics,
scope of practice, work load, income, and employment
arrangements in a sample of more than 400 CRNAs. They
found that CRNAs who practiced in ACTs were more
likely to be women, have less experience, be younger, have
a masters degree, and practice in larger cities. ACT-based
CRNAs also had a broader scope of practice and used more
airways, regional anesthesia, and monitoring techniques,
and performed more varied cases and services. They used
more laryngeal mask airways and arterial catheters, and
provided more anesthesia for cardiopulmonary bypass,
pediatric, intracranial, and trauma cases than non-ACT
anesthetists. However, they were less likely to be involved
with the placement ofepidural and central venous catheters
and to participate in pain management and critical care
services (Shumway & Del Risco, 2000).
NonACT-based anesthetists worked more hours
per week and were reimbursed $40,000 more per year.
Josh has been a CRNA for 20 years. He began his
career in a large university-based medical center focusing on cardiac cases. He subsequently developed
the skills and expertise to rotate through different
cases including craniotomies. As outpatient surgical
centers began to open in his area, he thought about
transitioning to a position in the community. However, he had a friend who had been doing this for
several years, and although the hours were better
and the stress level lower, she missed the challenge
of working with acutely ill and medically complex
patients and felt unprepared to return to a high-acuity
Josh ultimately decided to leave his hospital-based
job and work per diem as an independent contractor.
Because he is a seasoned clinician with a broad skill set
and a great local reputation, he found work in many
settings including a community hospital, university-based
medical center, and surgicenter. He has the best of both
worlds in that he can make his own schedule, experience the challenges of managing high-acuity patients,
and work moreindependently in the outpatient arena.
Box 2.6
Certified Registered Nurse Anesthetist Clinical Profile

32 Unit 1 The Evolution of Advanced Practice
APRNs are thriving, as shown in the increased numbers
of practitioners; in the expansion of practice roles and
settings; in the opportunity for independent practice without physician collaboration or supervision; and with the
support of major health-care organizations; for example,
the Veterans Healthcare Association endorses their use
throughout their health-care network (U.S. Department
of Veterans Affairs, 2016).
The future for APRNs is promising but will continue
to be affected by knowledge development in the biological
and social sciences and in the evolving political and social
climate. What effect this will have on APRN practice is
yet to be seen.
Care and Oncology, there has been a shift to increase access
to patients with other life-limiting illnesses such as neurological and cardiopulmonary disease. All APRNs have a
role in palliative care. As nurses first, APRNs have always
focused and excelled with symptom management, assessing
patients responses to treatments and ascertaining patients
goals. CNSs and NPs are the roles many people think of
as being the typical palliative care provider; however, the
palliative care APRN can also be a nurse-midwife, as these
professionals are skilled in managing individuals through
life transitions, pain, and anxiety, or a nurse anesthetist,
who may participatein palliativesedation (Van Hoover &
Holt, 2016; Wolf, 2013). Certification as an advanced
practice hospice and palliative nurse (ACHPN), often
a job requirement for this specialty area, is available for
the CNS and the NP through the Hospice and Palliative
Nurses Association (

Role Development
A Theoretical Perspective
Lucille A. Joel
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Explain structural-functionalist and symbolic-interactionist theories and how they
influence role adjustment.
Define reference groups and distinguish between normative, comparison, and
audience groups.
Evaluate role-taking and role-making in the workplace and explain the role of
socialization in these processes.
Explain the nature of second-order change and how it leads to the development of
new behaviors.
Apply the skill acquisition model to nursing (Benner, Dreyfus, & Dreyfus).
Describe setbacks experienced by new role expectations.
Justify the need for anticipatory socialization during the educational process.
Discuss challenges to socialization in the advanced practice nurse (APN) role.
Distinguish stress and strain.
A nurses role is constantly changing. There is no role
that a nurse will serve exclusively for the entire life of
a career. Role modifications depend on a theoretical
body of knowledge, more of it hypothetical than
empirical research. These concepts and relationships
allow a comfortable paradigm shift as necessary, with
an awareness of the elements of continuity from here
to there.

34 Unit 1 The Evolution of Advanced Practice
Altruism also plays a major part here because individuals subordinate their will to the social order. The social
forces in a given society validate the roles and the associated behaviors of the individual. Consensual validation
is the vehicle for both the maintenance and change of
these norms. In many instances, norms are codified by
government; in others, they continue to exist in veritable
limbo, changing or resisting change according to time and
place. A continuing debate exists about the relationship
between the fixed norms of a society and the individuals
perception of those norms. Often thereis no routeto interpretation of the social norm except cues offered by others
in the situation, and often those cues may be misleading.
From another perspective, where may nonconformity
be tolerated, to what degree, and in what areas of social
participation? Examples abound both professionally and in
life. Consider for a moment the immigrant family whose
children are schooled in the United States and socialized
to the prevailing culture in this country. Are their new
ways accepted at home and to what extent? Must they
change the way a chameleon does from place to place or
jeopardize belonging or perhaps even sustenance?To what
extent can advanced practice nurses (APNs) feel confident
in establishing their personally preferred values, attitudes,
and behaviors in a new role or employment situation? See
Box 3.1 for cues that may predict limits on flexibility in
defining role behaviors.
In contrast, the symbolic-interactionist view emphasizes
the meaning that symbols hold for actors in the process of
There are two diametrically opposed theoretical perspectives in the behavioral sciences that provide a
context for the study of role performance: structuralfunctionalist theory and symbolic-interactionist theory.
Structural-functionalist theory is based on the assumption that roles are more or less fixed within the society
to which they are attached and that opportunities for
individuals to alter patterns of social interaction are
limited. In contrast, symbolic interactionist theory
proposes the more individualistic perspective, that
people do not merely learn responses but organize and
interpret cues in the environment and choose those to
which they wish to react (Conway, 1988).
Structural-functionalist theory subordinates the individual to the society; it is deductive in its analysis of role. All
situations that arise within a society do so because they fill a
social need. One such example is the division of labor. The
more complex a society, the more differentiated its labor
source will become, readjusting and reconstructing over
time. Specialization becomes guaranteed, and associates
and assistants are created to share in a domain of the work.
This concept is dramatically displayed by the division of
labor and reordered roles within the health-care delivery
system, each role creating its own cadre of technologists,
technicians, associates, and assistants. Why should nursing
be different?
Highly precise and detailed job descriptions
Management by memorandum in situations in which
personal communication would have sufficed
Guarded interdisciplinary boundaries that hamper
smooth operation
A hierarchy that is an obstacle to work rather than a
Policies, procedures, and documentation systems
that are cumbersome and even inconsistent with
current practice
Absence of staff nurse autonomy in caring for patients
Organizational relationships designed for supervision,
as opposed to reporting
Absence of inventiveness and creativity
Verbalized discontent from staff, but no evidence of
any attempt to change things
High turnover rate among employees
Maintenance of a screen for attitudes, values, and
behaviors not supported by historic antecedents
Box 3.1
Cues That May Predict Limits on Flexibility in Defining Role Behaviors

Chapter 3 Role Development 35
role development, rather than the constraints presumed to
be exerted by the social structure. The interactionist sees
the formation of role identity as inductive and complex.
The role is a creative adaptation to the social environment
and the result of the reciprocal interaction of individuals.
It is the product of self-conception and the perspective of
generalized others. To facilitate communication toward
these ends, symbols are essential, and they must be social
and hold the same meaning for each actor in the process.
In other words, self-identity is shaped by the reflected
appraisals of others, and it is desirable that individuals
self-perception should be highly congruent with the way
they are perceived by others and the way they see themselves as being perceived by others. Should these pieces
show a poor fit, an individual could waste a lifetime of
effort creating evidence that justifies his or her personal
view of self.
Many have rejected the structuralist approach because
it seems limited in accounting for the wide variation in
roles and behaviors that we see today. Yet, it is impossible
to ignore the effect that the culture and the collective
conscience have on our development of identity and role
behaviors. There is recent interest in building conceptual
frameworks that are inclusive of both the interactionist
and structural perspectives, and promise a greatly enlarged
understanding of role development. This eclecticism
characterizes this chapters discussion.
The concept of reference groups and the process of socialization are central to role development. Reference groups
are the frame of reference for the process of socialization.
Through socialization, individual behavior is shaped to
conform to the standard of the group in which one chooses
to seek membership.
Reference Groups
Reference groups convey a standard of normative behavior
in terms of values, attitudes, knowledge, and skills. For an
individual, this may be a group to which he or she belongs
or aspires to belong. In moving toward a standard that is
either consciously or unconsciously desired, discussion of
several reference groups is in order, including normative
groups, comparison groups, and audience groups. The
normative group sets explicit standards and expects compliance, and it rewards or punishes relative to that degree
of compliance. The church, community, and family are
good examples of normative groups. The behaviors that are
expected may have wide or narrow latitude, but somewhere
there is a bottom line.
The comparison group sets its own standards and
becomes a comparison group only when an individual
accepts it as such (Lum, 1988). The nursing staff of a
Magnet facility may be a comparison group, demonstrating longevity in employment and satisfaction with work,
seeking upward mobility through education, and so on.
The nursing staff and their leadership in other facilities
may aspire to these qualities, making it a comparison
group for them.
The audience group is a collective group whose attention an individual wishes to attract. The audience group
holds certain values but does not demand compliance
from the person for whom they serve as a referent (Lum,
1988). In fact, the audience group may not even be aware
of this individual. To be recognized, the individual takes
note of the groups values and plays to that audience
for attention. Staff nurses may observe that physicians
value being able to proceed with the treatment of their
patients unencumbered by the bureaucratic constraints
of health care. Administrators are overwhelmed by the
cost factors in health care. Nurses are best positioned if
they are aware of these values and attitudes, and try to
minimize the obstacles they represent to these groups.
In other words, they play to the audience through either
word or deed.
Socialization refers to the learning of the values, attitudes,
knowledge, and skills that enable the behavior prescribed
for a specific social position or role. The fact that these
components are society-specific indicates that there are
social norms involved. Values are ideas held in common
by members of a social structure that prioritizes goals and
objectives (Scott, 1970). Values are generally the abstract
but relatively stable aspects of a persons belief system.
Attitude is the tendency to respond to social objects or
events in a favorable or unfavorable way. Opinion is
defined as expressed attitude. Behaviors are observable

36 Unit 1 The Evolution of Advanced Practice
not permanently achieve a desired result. Old preferences
keep returning the way antagonists do because we shift our
behaviors, but not the core values or attitudes causing the
behaviors. Second-order changes are permanent attitude
shifts that cause new behaviors (Watzlawick, Weakland, &
Fisch, 2011). The old ways stay gone and are not replaced
by a new version (such as giving up alcohol and starting
a nicotine or work addiction).
In contrast, role-making is bidirectional and interactive, with both actors presenting behaviors that are
interpreted reciprocally for the purpose of creating and
modifying their own roles. This process is analogous to
a dance, with each partner seeking to complement the
other while maintaining his or her own uniqueness. For
example, the APN notices surprisefrom the physician when
suggesting a modification in treatment for a patient. The
APN supplies cogent and sophisticated reasoning, and the
physician agrees, although skeptical of this behavior. Over
time, the physician becomes comfortable with the APNs
prescriptions and actually looks for the clinical input.
Both role-taking and role-making depend on success in
reading role partners correctly. This skill is enhanced by
broad social experience, rehearsal of the role anticipated,
the recentness of those experiences, attentiveness to role
behaviors, and good memory skills. These skills can be
developed and honed during the educational experience
(Ter Maten-Speksnijder, Grypdonck, Pool, Meurs, &
Van Staa, 2015).
Equally challenging as internalizing role behaviors
is the movement from one role or subrole to another.
This process is described in Box 3.2. Not only must one
learn new behaviors, but one must break from old ones.
Inadequate socialization predicts marginalization or the
inability to either remain in a previous role or move on
to another. A case in point is the nurse who hangs on to
the periphery of a system, never quite becoming part of
it or bothering to know the personalities involved and
refusing to assimilate nursing with the other aspects of life.
This is particularly common in people who try to juggle
multiple aspects of life, keeping each separateobligations
everywhere, multiple lists of things to do, each with a
first-place priority, a comprehensive plan nowhere. The
wiser strategy is to integrate the dimensions of life, with
professional colleagues becoming personal friends, family
participating in workplace and professional events, and so
on (one list with one rank ordering of priorities).
social acts performed by an individual. Attitudes guide
judgment and subsequently behavior, but this assumption of a relationship between attitude and behavior is
Operationally, the concept of socialization refers to
individuals acquiring the necessary knowledge and skills,
as well as internalizing and shaping the values and attitudes
of a particular social system, in preparation for fulfilling
a specific role in that system (Lum, 1988). This process
is no less true for the roles of nurse and APN than it is
for the role of mother, father, husband, or wife. Further,
whereas some roles or statuses have highly specific role
prescriptions, others are extremely vague and open to wide
variation of interpretation. This latitude may be observed
in the setting in which the role is played out, the society
in which it is placed, or both. Harmony among these
systems enhances role execution. There is often significant
discrepancy between the public, professional, legal, and
institutional definitions of the role of the nurse. Even if
the society and role occupant are bound by the legal role
as defined, discrepancies among the other definitions cause
problems in recruitment, retention, job satisfaction, and
more (Harley-Wilson, 1988).
Socialization is a continuous and cumulative process
thatevolves over time through role-taking and role-making,
both of which are techniques of role bargaining. Social
behavior is not simply a learned response. It depends on
the processes of interaction and communication. To be
successful, role-taking requires skill in empathic communication. The individual must project him- or herself into
the circumstances of another and then step back to imagine
how he or she would feel in the others situation. If there
is accurate determination of the motives and feelings of
the other, the actor can modify his or her own behavior
to sustain or alter the others response (Hardy & Hardy,
1988a). The process hereis unidirectional. Forexample, the
APN reads his or her peers and supervisor as seeing staff
development as the major focus of the APN role, although
she or he may have preferred to carry a significant personal
caseload of the most complex patients. Staff development
is accepted as the priority, but the APN takes on cases as
vehicles for teaching at every opportunity.
Put in another way, the less desirable activities are
accommodated (first-order change) and even eventually
assimilated (second-order change), becoming an integral part
of the role. First-order changes are behavioral shifts that do

Chapter 3 Role Development 37
Break From Previous Roles
Minimize previous advantage.
Break previous peer relationships.
Convert previous peer relationships into friendship
Maintain a portfolio or clinical log reflecting on
your evolving practice, values, and attitudes.
Establish a New Peer Group
Clarify new responsibilities that accompany changed
Consider the values, attitudes, knowledge, and skills
that will contribute to success.
Develop new peer group associations.
Move to the New Role Prescription
Provide role rehearsal opportunities.
Review benefits of mastery.
Consider a mentor.
Identify support systems among role partners.*
Assimilate Role Behaviors
Be aware of change of self-concept.
Recognize therites of passage as morethan symbolic.
Create opportunities for success.
Treat failure as a learning experience.
Move on to process and outcome evaluation once
the role is established, although not matured.
Box 3.2
Socialization as a Continuous Process
*A role partner may hold the same role or a role that is reciprocal but
definitely has role expectations of the primary role occupant.
Role Acquisition
Knowledge and skill acquisition are important aspects of
role implementation in nursing, both for the entry-level
registered nurse and for the APN. This is not to ignorethe
essential part played by attitudes and values (the belief system),
but to acknowledge that knowledge and skill are expected
of professionals by the public (audience group), leadership
in the field (comparative group), and peers (normative
group). Theskill acquisition model, developed by Dreyfus
and Dreyfus (1977) and later applied to nursing by Benner
(1984), tells us that even experts perform as novices when
they enter new roles or subroles, although they proceed
to acquisition at a quicker pace. This pattern is verified
by several authorities, including Brykczynski (2000) and
Roberts,Tabloski, and Bova (1997). In observing APN students, they report periods of regression, anxiety, and conflict
beforetheincorporation of new role behaviors. This is not
unexpected, and an analogy can be drawn from work with
groups. It is common that in the beginning of a group or
when a new member is introduced into an established group,
there is a loss of confidence among individual members.
The introduction of a person into a milieu with new role
expectations is a temporary setback, even when some of
the behaviors have been wellestablished in a previous role.
Theregression and loss of confidence are often followed by
anger directed toward faculty and preceptors whom they see
as guilty of not giving them enough knowledge or skill. In
many ways, they are grieving the role they had previously
mastered and responding to the anxiety over moving on.
Anticipatory socialization should be a planned goal
during the student period and not left to chance. Ample
opportunity should be provided for students to get to
know APNs who may just be beginning their careers
(peer group) and to participate in discussions with seasoned APNs regarding practice issues (accommodation).
Both of these goals may be accomplished through the
state nurses association, especially if there is a forum or
division on advanced practice. Other experiences should
be incorporated in the educational program, such as the
opportunity to dialogue with employers and practicing
APNs about their expectations of the role. Box 3.3 contains a format for the participation of APNs on a panel
describing their practice and role development for students.
These anticipatory experiences should facilitate the period
of resocialization as a graduate.
It would be remiss not to mention the clinical competency of faculty. Clinically competent faculty are necessary
to give credibility to the program and to narrow the gap
between education and practice (Brykczynski, 2000,
p. 121). The best of all worlds would be for faculty to teach
using their own panel of patients. Although this is often
impossible, it is still necessary for faculty to maintain their
clinical skills to be able to critique practice and provide the
proper oversight for preceptors (Moore & Watters, 2013).

38 Unit 1 The Evolution of Advanced Practice
Benner (2001) describes five levels of skill acquisition: novice, advanced beginner, competent, proficient,
and expert. As one proceeds along this continuum, one
becomes more involved in the process of caring, until
at the expert stage, situations are recognized in terms of
their holistic patterns rather than a cluster of component
parts, and the context becomes somewhat irrelevant. In
the early stages, new behaviors are accommodated, and
they later become assimilated in the practice repertoire,
until at the highest level they appear intuitive. Movement
from accommodation to assimilation or from novice to
expert with its intermediate steps is best accomplished
through accruing experience with the opportunity to
apply both practical and theoretical knowledge, and providing situations in which failure is allowed and treated
as a learning experience (Roberts et al, 1997). It should
be noted that Benners model is experiential and does not
consider education as a variable in distinguishing these
skill levels. However, you cannot apply what you do not
know. It would be interesting to use Benners model to
compare an APN and a nonmasters-prepared registered
nurse, both with similar experience.
How did you find your first position after graduation?
What job-seeking strategies would you advise new
graduates to use in todays market?
How do any or all of the following fit into your specific
What is your prescriptive authority?
What kind of practice privileges (i.e., admitting, treating,
consulting, and discharging) do you have?
What system do you have for reimbursement?
Do you participate in a managed-care panel?
How have your functions or role changed over the years,
and were those changes the result of the evolution
of the profession, your choices, your advocacy, or
the expectations of an employer?
Have you been an active participant in developing
your role? How so?
What arethe major stresses and strains in your practice?
How do you handle them?
Describe your collaborative arrangement with a
How do you show outcomes or document the value
of your contribution to the practice (or to your
How do you maintain your practice credibility?
Do you plan to further develop your own role or skill
set? If so, how?
What were the most valuable aspects of your graduate
educational preparation for advanced practice? The
least valuable?
What do you know now that you wish you had known
earlier in your career?
What is your experience with mentoring, either as
mentor or protg?
How important to your professional development was
this mentor(ed) experience?
Box 3.3
Questions to Guide Advanced Practice Nurse Participation in a Panel on Advanced Practice
It is helpful for APN students to consciously approach the
socialization process knowing their normative, comparative,
and audience groups, and being aware of the changes that
are expected to take place in their own behaviors, values,
and attitudes. Socializing experiences, provided during
the course of studies, are presented in Box 3.4.
Socialization Deficits
One of the most compelling challenges in professional
education is to provide adequate socialization. Socialization deficits are guaranteed to inhibit role performance,
introducing additional stress into roles that are already
by nature stressful.
APNs areincreasingly prepared in programs of part-time
study. In addition, the movement into the community
college and university settings forentry-leveleducation has,
to some degree, diluted the intensity of the socialization
experience for nursing. Off-campus living arrangements,
a cohort of students who depend on full-time or part-time
employment or who have family obligations, courses of
study that may be protracted over many years, and so on,

Chapter 3 Role Development 39
Stress and strain are natural companions of advanced
practice, given the chaotic health-care environment and
the fact that these roles are evolving and growing in
prominence. Hardy and Hardy (1988b) tell us that role
stress is primarily located in the social structure, external
to the individual, and owing to incompatible normative
expectations. It may or may not generate role strain, the
feeling of frustration and anxiety internal to theindividual.
Antecedents of Stress and Strain
Many situations can create stress and strain for the APN.
These include the educational preparation in which we
may overlook opportunities for anticipatory socialization
and in a rapidly restructuring health-care delivery system
that demands continuous minor or major modification in
roles. Specialization and advances in technology makeroles
that have become well established over time obsolete and
require the role occupants to face a new cycle of ambiguity
and transition (Creakbaum, 2011). Beyond this, there is
also the growing emphasis on costefficiency, consumerism,
and the demedicalization of health care. None of these
trends are surprising to the reader, but the effect they
have on roles is often unexpected and unintended. The
traditional hierarchy of the system is radically changed,
and the primary care provider is as likely to be an APN or
physician assistant as a physician. Consumer is king, and
health-care organizations are competing to corner their
market share of clients. Consumer satisfaction is a major
outcome measure against which everyone is measured.
Given the availability of information, consumers often
enter the system with as much information about their
condition as the professional who attends them. At the
same time, we see the slow but decisive movement toward
complementary therapies that have not been part of our
nursing repertoire in the past, but that are demanded by
the public.
To further complicate the situation, reality finds most
nurses as employees in health-care systems. One should
never lose sight of the fact that systems (whether large or
small, simple or complex) exist to secure their goals and
preservetheir values. They accomplish this by responding to
changing conditions, achieving solidarity among their parts,
using a division of labor to accomplish work, controlling
all reducethestrength of the primary socialization into the
profession. What is the result of an incomplete or weak
primary socialization into nursing when moving on to
the next roletransition to advanced practice(Chen, Chen,
Tsai, & Lo, 2007)? This remains a serious question yet to be
answered. Further,even if the primary socialization is solid,
what does incomplete anticipatory socialization as an APN
mean for role acquisition? This could create a situation of
marginal man, in which a person is a member of one or
more cultures but belongs to none. It also presents a strong
caseforexternships and residency programs through which
a concentrated exposureto theroleis guaranteed (Santucci,
2004; Starr, 2006). Certification also promises to help role
acquisition and role progression with its expectation of
additional education and investment in practice.
A synthesis semester at the end of the educational
program that incorporates, as far as legally possible, all the ingredients of full-time employment
Work-study programs that alternate semesters with
work placements in your anticipated field
A curriculum that progresses toward more independence and personal accountability, with students
and faculty moving to a collegial relationship as
opposed to superiors and subordinates
Service-education partnerships, with faculty teaching
students as they practice with their own patients
Opportunity for students to work with faculty on
their personal research or in their practice
Summer externships and new graduate internships
or residencies
Patient clinical areas with a primary commitment
to the clinical learning needs of students (the
designated teaching unit)
Participation in activities suited to APNs (e.g.,
conferences, meetings, and peer review sessions)
Preceptor or buddy system involving agency staff
An experience with interdisciplinary (or at the least
multidisciplinary) education (Joel, 2011)
Box 3.4
Role-Enhancing Experiences Planned
During Your Education (Applicable to Either
Entry-Level or Graduate Education)

40 Unit 1 The Evolution of Advanced Practice
overqualified or are moving into a new role or are engaged
in anticipatory socialization. An example of ambiguity
is the new APN who accepts a position without an adequate job description in a setting where there has been
little experience with advanced practice, and so there are
no seasoned peers to provide direction or support. An
example of incongruity is the nurse who has been prepared exclusively for primary care practice and accepts a
position that requires extensive coaching and teaching of
nursing staff in a specialty area. Role conflict may result
when the staff nurse feels an obligation to provide quality
care but then finds it impossible to achieve satisfactory
outcomes within the limits of a predetermined length of
stay or in a situation in which the nurse believes that his
or her clinical judgment is superior to the clients own
choices, but the client refuses to comply. Overload and
underload often require a more objective opinion as well
as the self-assurance to revisit goals and objectives to make
them more realistic. Being overqualified or underqualified
moves into areas of competence. Some individuals may
consider themselves overqualified because they never
strain to see or are untrained to see the complexities of a
situation. The same circumstances may give rise to feelings
of underload. Peer discussion of such clinical situations is
helpful to verify your opinion of yourself. Feelings of being
underqualified must be talked through and validated, or
they result in living the life of an impostor (Arena &
Page, 1992).
The stress and strain that come with most of the service occupations are labeled codependency or burnout in
the literature. These two terms are related but different.
In codependency, a person controls a situation through
the assurance that he or she is needed and works to keep
things that way, whereas in burnout there is difficulty
determining who owns a problem. The result is anger
stemming from the moral imperative to make a difference,
yet the inability to succeed. The natural impulse of nurses
to feel for their patients and occasionally bring home their
frustrations is played out with exaggeration and eventually
rejected. With time, where once they felt too much, they
now feel too little in defense of their ego. The result is poor
judgment, insensitivity, and intolerance (Joel, 1994). This
is the end result of burnout. The codependent personality
is at particularly high risk for burnout, which eventually
results in negativism and the severe loss of self-esteem as
ones clinical competence is questioned.
the environment, maintaining order, and using resources
efficiently. Efficiency has caused a move to accomplish
many things through adhocracysystems established
for a limited goal and then disbanded. Subcontracting in
addition to internal departments allow greater flexibility
to adjust to change. In a similar manner, the nursing role
has been forced to readjust or jeopardize organizational
stability (Ball, 2011), so resocialization becomes a continuing process, and stress and strain a constant by-product
of this process.
Classifying Role Stress
After an exhaustive analysis of research on role stress as
it existed in 1988, Hardy and Hardy (1988) developed
the classification system presented in Box 3.5 that was
subsequently expanded by the work of Schumacher and
Meleis (1994).
Stress and strain are predictable in situations that
include ambiguity, ambivalence, incongruity, conflict,
and underload and overload, and in situations in which
the role occupants see themselves as underqualified or
Role ambiguityThere is vagueness and lack of
clarity of the role expectations.
Role conflictRole expectations are incompatible.
Role incongruityThere is a poor fit between the
persons abilities and theirexpectations or theexpectations of thesystems with which they interface.
Role overloadThere is too much expected in the
time available.
Role underloadRole expectations are minimal
and underuse the abilities of the role occupant.
Role overqualificationRole occupants motivation,
skills, and knowledge far exceed those required.
Role underqualification (role incompetence)Role
occupant lacks the necessary resources (Hardy
& Hardy, 1988b).
Role transitionPerson moves to a new role.
Role supplementationThereis anticipatory socialization (Schumacher & Meleis, 1994).
Box 3.5
Classification of Role Stress

Chapter 3 Role Development 41
become rutters (staying in a rut), with an its a job
attitude, or they may eventually reject the values of both
themselves and the system. Others become organization
men and women, who move rapidly into the administrative ranks and totally absorb the bureaucratic values.
Those who will change neither values nor behavior, what
might be called going it alone, either seek to practice
where professional values are accepted or try the academic
lateral arabesque (also used by the first group), going on
to advanced education with the hope of new horizons or
escape. The most desirable choice, says Kramer (1974,
p. 162), is biculturalism:
In this approach the nurse has learned that she possesses a value
orientation that is perhaps different from the dominant one in
the work organization, but that she has the responsibility to
listen to and seek out the ideas of others as resource material
in effecting a viable integration of both value systems. She has
learned that she is not just a target of influence and pressure
from others, but that she is in a reciprocal relationship with
others and has the right and responsibility to attempt to
influence them and to direct their influence attempts . . . she
has learned a basic posture of interdependence with respect
to the conflicting value systems.
Even though complicated by the bureaucratic-professional
conflict, our original paradigm for socialization is visible
in biculturalism.
New graduates do indeed go through variations of
this experience, including role-taking, role-making, and
bargaining. That there was little change in the adjustment
process for decades can be seen by reviewing journals in
the interim and by the nomadic workplace patterns of
nurses, which must reflect deep-seated job dissatisfaction.
Turnover may be a response to boredom, lack of involvement, and apathy, and may trace its origin to incomplete
or ineffective socialization, or more correctly, ignorance
of the socialization process. Hardy and Hardy (1988a)
propose that strain may be handled by redefining the role
or its expectations, by bargaining among role partners to
reestablish priorities, or by decreasing or increasing the
degree of interaction.
Managing Role Strain
There is no one prescription for coming to terms with an
unmanageable personal or professional life. The problems
are relative to the personality of the afflicted, and solutions
Responding to Role Strain
Kramer (1974), in an extensive longitudinal study that
is still relevant after 40 years, identified the problems of
new graduates in establishing their roles in the midst
of bureaucratic-professional conflict and termed it
reality shock. Kramer speaks of the specific shock-like
reactions of new workers when they find themselves in
a work situation for which they have spent several years
preparing and for which they thought they were going
to be prepared, and then suddenly find that they are not
(p. vi). When the new nurse, who has been in the work
setting but not of it, embarks on a first professional work
experience, there is not an easy adaptation of previously
learned values, attitudes, and behaviors, but the necessity
of an entirely new socialization to practice and simultaneous resolution of conflict with the bureaucracy. This
process of resocialization from student to graduate can
be easily applied to the APN. Kramer (1974) describes
the steps as follows:
Skills and routine mastery: The expectations are those of the
employment setting. A major value is competent, efficient
delivery of procedures and techniques to clients. New graduates immediately concentrate on skill and routine mastery.
Social integration: [Social integration is] getting along with
the group; being taught by them how to work and behave;
the backstage reality behaviors. If individuals stay at stage
one, they may not be perceived as competent peers; if they
try to incorporate some of the professional concepts brought
over from the educational setting and adhere to those values,
the group may be alienated.
Moral outrage: With the incongruence identified and
labeled, new graduates feel angry and betrayed by both their
teachers and employers. They werent told how it would be
and they arent allowed to practice as they were taught.
Conflict resolution: The graduates may and do change
their behavior, but maintain their values, or change both
values and behaviors to match the work setting; or change
neither values nor behavior; or work out a relationship that
allows them to keep their values, but begin to integrate
them into the new setting (pp. 155162).
The individuals who make the first choice have selected what is called behavioral capitulation. They may
be the group with potential for making change, but they
simply slide into the bureaucratic mold, or more likely,
they withdraw from nursing practice altogether. Those
who choose bureaucracy (value capitulation) may either

42 Unit 1 The Evolution of Advanced Practice
Socialization into role is a major responsibility of the
nursing profession, whether at the point of immersion
into the student role and anticipatory socialization to the
profession or later with transition to registered nurse and
for some on to advanced practice. Socialization requires
personalizing a role to your preferences while complying
with norms established by the government, the profession,
the public, and the employing institution. These are your
normative, comparative, and audience groups, your major
referents; there may be others. The norms held by these
groups may be broadly or narrowly interpreted and are
revealed through the process of role-taking or empathic
communication. There is an opportunity to modify these
expectations once you aresensitive to the degree of flexibility allowed by each referent system. This process involves
skill in reading our role partners and the environment
and reciprocally working to make the role to our liking.
This skill can be learned.
Stress and strain are natural companions to nurses,
given the environment in which we work and the work
we do. Role stress is located in the social structure, and
role strain in the person. Not all stressful circumstances
produce strain; this depends on the individual and his or
her ability to cope, problem solve, and search for meaning
in difficult situations. Success in dealing with stress and
strain may be related to complete and effective socialization. This observation reinforces the obligation to both
provide socialization experiences and to equip nurses with
the resources for self-care.
must be individualized. The ultimate goal is to establish
control and identity that is driven by internal strength,
rather than being captive to the volatility of the environment. Given that your best investment is in self-care,
consider the following (Joel, 2011, p. 584):
Learn to use distance therapeutically. Allow people to fail
and learn from their own mistakes.
Find a comfortable and private place to which you can
retreat when you arestressed. If you cannot physically distance
yourself, try meditation techniques.
Decide who owns a problem. If you dont own it, you have
no obligation to fix it, especially if it requires self-sacrifice.
Examine the quality of the peer support you give and
get, and correct the situation if needed. Sometimes support
systems become habits as opposed to helps.
Invest in upgrading yourself. Expose yourself to new
experiences; learn new skills. Plan your self-care as seriously
as you plan your patient care.
Consciously schedule routine tasks and those requiring
physical exertion as a break from complex and stressful
Learn to trust your instincts. Every problem does not
have a rational and logical solution.
Sometimes think in terms of what could be the worst
consequence, then anything short of that is a bonus.
Identify one person willing to serve as your objective
sounding board. This may be one way to find out how you
come across to people.
Make contact with your feelings about situations. Feelings
are neither good nor bad; they just are.
Create options for yourself. Identify those circumstances
that you need to personally control, those that are just as well
controlled for you, and those that you choose to wait out.

Educational Preparation
of Advanced Practice Nurses
Looking to the Future
Phyllis Shanley Hansell
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Understand the historical background of education for advanced practice.
Describe external factors that drive demand and influence education
for advanced practice.
Distinguish the advanced practice nurse (APN) role and educational requirements
for the nurse practitioner (NP), nurse-anesthetist (NA), clinical nurse-midwife
(CNM), and clinical nurse specialist.
Determine the factors that initiated interest in the doctorate of
nursing practice (DNP).
Identify distinctions in scholarship between the DNP and the PhD.
Explain the process of transition from MSN to DNP for the APN.
Compare the doctoral dissertation to the DNP project.
Propose potential synergy between the DNP and PhD.
Demonstrate a faculty role for the DNP graduate.
Anticipate the future for the DNP and PhD.

44 Unit 1 The Evolution of Advanced Practice
of Directors convened a task force to review the state of
DNP programs in order to better clarify both curricular
and practice expectations as outlined in the Essentials of
Doctoral Education for Advanced Nursing Practice (AACN,
2006) and to highlight practice scholarship and academic
partnership opportunities.
The 21st century has been a significant timefor nursing,
first with recognition by the Carnegie Foundation that
nursing has met the criteria for professional status, and
second, that APNs are being recognized for their important
contributions to health care. A major factor in this newfound
recognition has much to do with the exponential growth of
nursing science and translational nursing research that has
enlarged the foundation of scientific evidence supporting
nursing practice (AACN, 2010b).
One of the lingering controversies for APNs has to do
with the preferred academic credential forentry into advanced
practice. At thesemiannual meeting of the American Association
ofColleges of Nursing in 2004 (AACN, 2004), the member
deans present voted to endorse and support the DNP degree
as theentry-leveleducational credential for APNs,effective
as of 2015. The discussion that ensued in response to the
resolution was very heated.When the members secret ballot
votes weretallied, theresults were 162 in affirmative, 101 in
opposition, and 13 in abstention.Voices in opposition came
from two divergent factions of the assembly: deans that viewed
the DNP as beyond the resources of their institutions, and
deans of schools with highly developed and well-funded PhD
programs. I voted in the affirmative, as I believed that the
APN curriculum fell short in both depth and breadth, had
become increasingly narrow, and needed to be broadened.
In addition, for APNs to achieve parity with other major
health professionals, a terminal clinical practice degree would
both reinforcethestatus of nursing as a major autonomous
health-care provider and enable the achievement of better
patient care outcomes. Other major considerations werethe
proposed requirement of 1,000 supervised hours of clinical
practice along with the focus on clinical scholarship and
analytical methods for evidence-based practice.
The movement to advance doctoraleducation for nurses
in the United States is strong and has gained significant
momentum. According to AACN (2016) data, there
are currently 403 doctoral level nursing programs in the
United States: 134 PhD programs and 269 DNP programs.
Interestingly, most schools that offer the PhD nursing degree
also offer the DNP. There arefew exceptions to this pattern
The education of advanced practice nurses (APNs) has increased in complexity as curricula have evolved in response
to societal needs. These curricular changes are primarily in
response to health-care reform and the transformation of
health-care delivery brought about by the Patient Protection
and Affordable Care Act (PPACA) (Public Law 111-148).
Henry Silver and Loretta Ford created the first certificate
program for nurse practitioners (NPs) at the University
of Colorado in 1965; since that time, the NP role and
educational preparation for the role has been met with
some degree of controversy from both inside and outside
of the nursing profession. This dissonance has extended
beyond NP education and also includes nurse-midwives,
nurse anesthetists, and clinical nurse specialists.
The PPACA (2010) has resulted in improved access
to health care, particularly for underserved populations
in rural and inner city areas, and subsequently increased
demand for primary health care. Many of the provisions
included in the PPACA acknowledge the important
contributions that nurses, especially APNs, have to offer.
The PPACA has therefore provided funded support that
includes (a) the establishment of nurse managed health
centers, (b) funding for school-based health centers,
(c) funding to support collaboration between nursing
schools and health-care facilities, (d) loan forgiveness
for individuals willing to practice in a pediatric subspecialty (including mental health) in an underserved area,
(e) funding to support Independence at Home Demonstration
for chronically ill Medicare beneficiaries that uses both
NPs and physicians and is aimed at reducing expenditures
and improving health outcomes, and (f ) an increase in the
reimbursement rate for certified nurse-midwives (CNMs)
for covered services from 65% to 100%.
These PPACA-funded initiatives will serveto support and
further deploy the professionalexpertise of APNs,enabling
them to make a difference in the delivery of health care,
especially to those who are underserved. A recent study by
the Rand Corporation (Auerbach, Martsolf, Pearson et al,
sponsored by Rand Corporation, 2015), commissioned
by the AACN Board of Directors, found that there is now
universal agreement within the nursing community on the
value of doctor of nursing practice (DNP) education that
is preparing nurses to meet the future health-care needs
(Auerbach, 2014). Because of this study the AACN Board

Chapter 4 Educational Preparation of Advanced Practice Nurses 45
with only 16 schools offering only the research doctorate.
At this time, there are DNP programs in 49 states with
online access delivering DNP education to all 50 states.
According to the AACNs 2015 Annual Report: Leading
Excellence and Innovation in Academic Nursing (2016),
113,788 students are currently enrolled in masters programs (including masters entry students), 5,290 students
are enrolled in research focused doctoral programs, and
18,352 students are enrolled in practice focused doctoral
programs. Although the master of sciencein nursing (MSN)
continues to be the predominant route to certification for
APNs, the trend is moving in the direction of the bachelor
of science of nursing (BSN) to DNP with MSN advanced
practice programs coexisting in 75% of schools that offer
the DNP. BSN to DNP programs currently comprise more
than half of existing DNP programs (with an additional
60 BSN to DNP programs reported to be in the planning
stage). Although the postbaccalaureate DNP is taking
hold, most nurses often seek the more expeditious option,
which is the MSN. At this time, the MSN still meets the
requirement for APN certification.
When one takes a retrospective look at the credentialing of NPs, it is noteworthy that in 1965, the certificate
became the first advanced educational postbaccalaureate
credential for the first generation of pediatric NPs (the
first NP role). Two years later in 1967, Boston College
introduced the first MSN with an NP track. Similar to
the certificate program at the University of Colorado, the
program at Boston College (Historical Timeline AANP.
org) included efforts that were collaboratively led by
nursing and medicine. As the educational requirements
for NPs uniformly advanced to the masters level, there
were many concerns arising over grandfathering NPs
with certificates when MSN degree preparation became
the standard requirement for certification (Ford, 1975).
Although there once was a defined period of grandfathering
for certificate NP graduates, there is currently no grandfathering clause remaining in any state that would allow
any APN (nurse-midwife, nurse anesthetist, clinical nurse
specialist [CNS], or NP) to enter into practice without
an advanced degree. It is important to note that because
advanced practice nursing is regulated by state statute,
older nurses with an advanced practice certificate have
been able to continue to practice so long as the state and
their specialty-certifying bodies recognize their status. In
the United States there are 50 different state nurse practice
acts (NPAs) under which the advanced practice roles are
regulated. For this reason, in 2008 the State Boards of
Nursing (NCSBN) introduced the Consensus Model for
APRN Regulation: Licensure, Accreditation, Certification and
Education, designed to provide some common structural
guidance for the preparation and practice of APNs.
APNs are prepared through a variety of educational
programs with oversight carried out by specialty certification boards; hence, there are different requirements for
different advanced practice roles. The American Midwifery
Certification Board (AMCB) and the American College
of Nurse-Midwives (ACNM) have eliminated recognition of all postbaccalaureate certificate programs, and in
July of 2009 required a graduate degree for entry into
practice, which went into effect in 2010 (ACNM, 2009).
Moreover, in 2009 the ACNM also moved to require
recertification for CNMs who were certified before 1996
to ensure the highest quality of nurse-midwifery care. In
1990, the Council on Accreditation of Nurse Anesthesia
Educational Programs (2003, 2004) moved to require
the masters degree requirement for entry into nurse anesthesia practice. It is important to note that the masters
degree is not mandated to be in nursing, as many nurse
anesthesia programs do not reside in schools of nursing.
The Council included a grandfather clause that allowed
current certified registered nurse anesthetists (CRNAs) to
continue to practice without obtaining a masters degree
(Kinslow, 2005). In September 2007 the American Association of Nurse Anesthetists (AANA) announced support
for doctoral level entry into nurse anesthesia practice by
2025 (AANA, 2007). The DNP degree was not specifically
endorsed, allowing for other types of doctoral education
to meet these criteria. In states where the status of CNS
is recognized, the masters degree in nursing is required
as the educational requirement for practice. In June 2015
the National Association of Clinical Nurse Specialists
(NACNS, 2016) endorsed the DNP degree as the entry
requirement for CNSs by 2030.
The typical MSN curriculum for APNs has become
highly focused on the specialty area of practice, leaving
minimal opportunity for students to select elective areas
of study. When one peruses the eight Essentials of Doctoral
Education for Advanced Practice Nursing (AACN, 2006),
the DNP offers much to round out the knowledge,
skills, and expertise of the graduate with the inclusion
of (a) interprofessional collaboration, (b) health policy

46 Unit 1 The Evolution of Advanced Practice
state nursing regulatory bodies and with the respective
advanced practice specialty organizations. Furthermore, the two chief accrediting bodies in nursing, the
Commission on Collegiate Nursing Education (CCNE)
and the Commission for Nursing Education Accreditation (CNEA, formerly The National League for Nursing
Accreditation Commission [NLNAC]), have elected
to accredit DNP programs. The CCNE has elected
to accredit only practice doctorate programs with the
initials DNP, whereas the CNEA believes as advanced
practice doctorates move in this new direction, they will
accredit whatever title suits the program, believing that
nursing is best served by focusing on competencies,
learning outcomes, and curriculum (CNEA, 2016)
(NLN-CNEA, 2016).
In the past, APNs who pursued doctoraleducation were
limited to research-focused doctorates such as the PhD,
DNSc, DNS, DSN, and EdD, as well as doctorates in other
disciplines. By 2008 most of the various nursing doctoral
degrees had converted to the PhD (Dreher, Fasolka, & Clark,
2008), leaving the PhD in Nursing as the professional standard
for research doctoral degrees in the field. APNsenter a new
conundrum with the emergence of the practice doctorate,
which is best suited to those who are dedicated practitioners.
Those who instead opt for the PhD degree havethe advancement of nursing science as their goal. Prospectively, as one
looks to the future when the DNP becomes the standard
for entry into advanced practice, the PhD will eventually
become the step beyond the practice doctorate, similar to
what exists in medicine where the MD/PhD is the degree
of choice for those with a research focus.
Transition From the MSN to the DNP
When experienced APNs continue their education at the
DNP level, what is the gain? I interviewed four recent
DNP students/graduates to find out what they gained
from the DNP program and how it changed them. Here
are the responses that I received:
1. The Doctor of Nursing Practice offers the highest
level of quality and safety to the patients in their care,
the nurses on their team and the system within which
they practice. Let us welcome this new recognition of
Nursing Practiceexcellence! Changed attitudes = changed
advocacy, (c) clinical scholarship and analytical methods
for evidence-based practice, and (d) organizational and
systems leadership and the scientific underpinnings of
practice. The AACN Essentials (2006) clearly augments
the 2015 MSN curriculum in needed ways by equipping
the APN of the future to create and advance patient care
as never before envisioned.
The American Association of Nurse Practitioners
(AANP) has been proactive, and although a masters
degree is required for certification of NPs, the board of
directors of the National Organization of Nurse Practitioner
Faculties (NONPF) reaffirmed its allegiance (NONPF,
September 2015) to advancing the DNP degree as the
entry-level academic preparation for NPs. Their statement
on the matter is as follows Now2015is our time to
make a commitment collectively on behalf of our students,
the profession and our patients to making NP education
doctoral-level preparation. The sooner the educational
standards for NPs advance to the DNP, the better it will
be for APNs and their patients.
It is clear that the coursework required in NP MSN
programs is rigorous and comparable with the coursework
required of typical clinical doctoral programs such as those
involving pharmacy and physical therapy. However, it is
tantamount that the transition to the practice doctorate
preparation continue to be conducted so that NPs collectively advance together in unity.
According to the AANP there are more than 359,194 NPs
licensed in the United States (AANP, 2016). The other
APN roles comprise a relatively small proportion of APNs
as follows: 77,000 CNSs, 49,000 nurse anesthetists, and
11,194 CNMs, among which 82% are prepared with the
minimum of a masters degree (American Nurses Association [ANA], 2011).
The goal to migrate all these APNs to the doctorate
(excluding those who already have the degree) is a highly
ambitious undertaking. Some question whether this is a
realistic goal when, in reality, the movement to require
the entry-level doctorate for advanced nursing practice
will be a complex process. Although the AACN has a
role in contributing to the development of standards, it
lacks the legal authority to enforce this on the various

Chapter 4 Educational Preparation of Advanced Practice Nurses 47
first professional degree that is a nonresearch doctorate.
An AACN task force was subsequently constituted in
2002 to explore the DNP. The report of this task force
provided the impetus for the 2004 vote by the AACN
membership, which then was followed by the development
and approval of the Essentials for the Practice Doctorate in
Nursing published in 2006. Other degrees considered
analogous to the DNP by AACN include doctorates in
medicine (MD), dentistry (DDS and DMD), pharmacy
(PharmD), psychology (PsyD), physical therapy (DPT),
and audiology (AudD) (AACN, 2011b).
Rationale for the DNP Degree
Despite the plethora of DNP programs, the numbers of
MSN students far outnumber thoseenrolled in BSN/DNP
programs. There are convincing reasons in support of an
entry-level doctorate for nursing. These include reform
in health profession education mainly because of rising
health-care errors, patient safety issues, and the changing
roles of providers; failure of the health disciplines to work
collaboratively and deliver optimal health outcomes; and
therising cost of health-careservices. The central arguments
for why the AACN advocated that entry into advanced
practice nursing should require the doctorate instead of
the masters degree are as follows: (a) masters in nursing
degrees,especially those preparing the NP, nurse anesthetist,
or CNM, often required as many credit hours as some
clinical doctorate programs in other disciplines; (b) other
disciplines such as physical therapy (DPT) and pharmacy
(PharmD) had begun offering a clinical doctorate; and
(c) contemporary knowledge is growing exponentially
and the masters degree can no longer fully encompass
the breadth of coursework necessary for advanced practice
(Apold, 2008).
As compelling as these arguments are, they are not all
data based. Although thestatement about thetotal number
of credits could be considered a salient one, the attainment
of credits aloneis not sufficient to merit the attainment of a
doctoral degree. One could arguethat the decades of strong
outcome data supporting the excellence of the APN, particularly in comparison to primary medical care(Horrocks,
Anderson, & Salisbury, 2002; Mundinger et al, 2000), is
reason enough to maintain thestatus quo. Such reasoning is
not without flaws, however, as it totally ignores the changes
that have evolved through health-care reform, the growing
2. The DNP has provided the essential knowledge necessary to translate evidence into practice in order to
improve health quality, costefficiency and sustainability
of effective processes.
3. Coming from such a strong clinical background, the
DNP program has helped meintegrate my collaborative
clinical practice and research with current trends in the
evolution of health care issues.
4. The DNP enabled me to recognize health delivery
system problems and conduct evidence-based scholarly
projects toward rectifying those issues.
Based on these quotes, it is evident that even for the most
experienced APNs there is much to be gained from the
DNP curriculum that will shape the APNs practice and
ultimately benefit the patient.
The Tipping Point for the DNP
The DNP is still a relatively new degree; it was first offered
by the College of Nursing at the University of Kentucky
in 2001, with nine students initially graduating with the
degree in 2005. (In contrast, the first EdD in Nursing
Education was first offered in 1932 at Teachers College,
Columbia University, and the first PhD in 1934 at New York
University.) The genesis of todays DNP practitioner-focused
model can be traced to Mary Mundinger of Columbia
Universitys School of Nursing. In 2000, Mundinger and
her colleagues published a clinical trial in the Journal of
the American Medical Association titled Primary Care
Outcomes in Patients Treated by Nurse Practitioners or
Physicians: A RandomizedTrial. This innovative project
at Columbia University on the NP model ultimately led
to development of the clinical doctorate or DrNP degree.
Columbias DrNP was finally approved in 2005. Nevertheless, even the Columbia DrNP model went through
an evolution during which the faculty first described the
degree as a DrNP in Primary Care, later simply the first
clinical doctorate (instead of a practice doctorate as it
is commonly called). In 2008, the degree was changed to
the DNP to comply with CCNE standards.
Before the presentation of the proposal for the DNP
degree, the AACN sponsored speakers from the American
Association of Colleges of Pharmacy at their semiannual
meeting. They presented their 10-year transition from the
bachelor of pharmacy to doctor of pharmacy degree, the

48 Unit 1 The Evolution of Advanced Practice
the DNP curriculum. In contrast to the PhD curriculum,
the DNP graduate engages as an APN, thus providing the
leadership for evidence-based practice, whereas the PhD
graduate acquires the research skills needed for discovering
new knowledgein the discipline. The DNP graduaterequires
competence in knowledge application activities including
translation of research into practice, practice evaluation of
the improvement of the reliability of health-care practices
and outcomes, and participation in collaborative research
(De Palma & McGuire, 2005). The graduates of research
and practice doctorates are both critical to the advancement
of the profession and are optimally complementary to each
other in the advancement of nursing science. The DNP
is not intended to be a watered down version of the PhD
or, as some may say, a PhD light; rather, it is a rigorous
professional practice terminal degree. If nursing science is
to advance practice, graduates of both degrees are needed
to achieve this important goal.
The Dissertation Versus the DNP Project
The hallmark of doctoraleducation is scholarship, and the
research doctorate in nursing is designed to prepare the
graduate with the research skills needed to discover new
knowledgeto advancethe discipline. In contrast, the DNP
prepares graduates to be experts in the practice of nursing
and to lead in theformulation and appropriate application
ofevidence-based practice. De Palma and McGuire(2005)
state that in order to provide leadership in translational
research, the graduate needs to be competent in thetranslation of research in practice, the evaluation of practice,
the improvement of the reliability of health-care practice
and outcomes, and participation in collaborativeresearch.
Accordingly, the DNP curriculum needs to focus on the
translation of new nursing science and its application and
For the research doctorate in nursing, the doctoral
dissertation is the culminating requirement through
which the PhD student is required to create new research.
The steps associated with the dissertation process across
programs in the United States is relatively standard. The
typical steps of the dissertation process include proposal
development and approval, data collection, data analysis,
aging population, and the implementation of the PPACA.
In our changed, complex world of health care, ANPs must
stay on top of their patients needs; more education about
health systems,evidence-based practice, and health systems
is in order.
The DNP degree has gained wide acceptance by the
academic nursing community, and it is highly probable
that candidates with a practice doctorate will have an
advantage in a highly competitive changing job market.
The nursing community is challenged to substantiate that
the added cost, time, and resources needed to educate the
DNP graduate will improve health care, as well as the
status and expertise of the practitioner.
The tipping point has been reached and the DNP
is well along on its way to acceptance especially within
the clinical practice arena. Within academia, the DNP
credential is accepted and well suited for clinical track
appointments. However, most major universities do not
accept the DNP for tenure track positions and require a
research doctorate for those appointments.
The DNP has existed for slightly more than a decade
with some of the early programs developed before the
AACNs Essentials of Doctoral Education for Advanced
Practice Nurses (2006). This has resulted in some degree
of irregularity from program to program, particularly concerning the final capstone project. Fink (2006) indicates
that the professional (or practice) doctorate should not
be a watered down version of the PhD, but offer a valid
alternative in doctoral education (p. 38). The AACN
Essentials (2006) state scholarship and research represent
the hallmark of doctoral leveleducation. Although original
research is paramount in the advancement of science, a
much broader view has emerged that enlarges that perspective through alternative paradigms (Boyer, 1990).
This perspective acknowledges the following: (a) The
scholarship of integration and discovery more specifically
reflects the investigative and synthesizing traditions of
academic life (Boyer, p. 21); (b) Scholars give meaning
to isolated facts and make connections across disciplines
through the scholarship of integration; and (c) The scholar
applies knowledge to solve problems via the scholarship
of application (in nursing this is practice).
Essential III of the Essentials of Doctoral Education
for Advanced Nursing Practice (AACN, 2006) specifies
that Clinical Scholarship and Analytical Methods for
Evidence-Based Practice is an important component of

Chapter 4 Educational Preparation of Advanced Practice Nurses 49
knowledge through innovation of practice change, the
translation of evidence, and the implementation of quality
improvement processes in specific practicesettings, systems,
or with specific populations to improve health or health
outcomes (AACN, 2015).
The AACN task force (2015) has clarified the scope of
the final scholarly project regarding the DNP. The title of
the project should be the DNP project to avoid confusion
with the dissertation. Because the DNP project is not a
research dissertation the term dissertation should not be
used. The scholarly DNP project may take on various
forms as stipulated by an institutions requirement along
with the students area of advanced practice, but should
remain standard for all students and include planning,
implementation, and evaluation components. Contrary
to the DNP Essentials (AACN, 2006), the task force
believes that an integrative and systematic review alone
is not considered a DNP project, and does not provide
opportunities for students to develop and integrate scholarship into practice (AACN, 2015b, p. 4). Additional
recommendations from the task force include (a) there
is no committee, but rather a project team; (b) the
dissemination of the project should describe its purpose,
planning, implementation, and evaluation components;
and (c) evaluation of the final project is the responsibility
of the faculty and should include academic, peer, and
stakeholder review. As a programmatic outcome of the
DNP curriculum, all students must have the opportunity to integrate all eight of the DNP Essentials (AACN,
2006, 2015a). They do not have to be demonstrated in
the DNP project, but rather through the completion of
the curriculum. As DNP programs mature into a unique
identity of their own and become more standardized and
consistent with the DNP Essentials (AACN, 2006) and
DNP task force recommendations (AACN, 2015a) there
will be increased congruence across DNP programs.
The Potential for Synergy
Between the PhD and DNP
In an articlein Nursing Outlook entitled Strategic Innovation
Between PhD and DNP Programs: Collaboration,
Collegiality and Shared Resources (Edwards, Rayman,
Diffenderfer, & Stidham, 2016), the authors share the
results of a collaborative DNP and PhD project within the
context of the EastTennessee State Universitys Academic
synthesis of findings, completion of a five to six chapter
dissertation, and oral defense of the dissertation. All this
occurs under the guidance and supervision of a dissertation
chairperson and committee.
The rapid growth of DNP programs has resulted in
significant variability in the final project or capstone requirement. Some DNP programs have required students
to complete a dissertation-type project that includes a
committee and oral defense; others have focused on the
generation of original practice research, whereas still others
require a systematic review of the literature on a clinical
topic with no actual involvement in the clinical practice
setting. In contrast to the dissertation process, there is
typically a mentor without a committee structure and
the final presentation of the capstone project is less of an
oral defense than a presentation of results of the project
to faculty and students.
Consistent with the AACN Essentials of Doctoral
Education for Advanced Nursing Practice (2006), Waldrop,
Caruso, Fuchs, and Hypes (2014) have defined five criteria
for executing a successful DNP final project. In order
for the DNP project to be consistent with the standards
articulated by the AACN (2006) and NONPF (2007),
they have stated that the project should address a complex
practice, process, or systems problem in the particular
setting. Evidence should then be used to improve practice,
process, or outcomes; this makes it clear that the DNP
graduate must actually have completed a project in the
practice setting and must evaluate what was implemented
to determine the outcomes (p. 302). This is in accordance
with Waldrop et al (2014), who represent the criteria
with the acronym EC as PIE where E = Enhance,
C = Culmination, P = Partnerships, I = Implements,
and E = Evaluates.
In 2015 the AACN convened a task force on the current
state of implementation of the DNP to clarify curricular
and practice expectations as outlined in the DNP Essentials
(AACN, 2006). An important outcome of the task force
was the articulation of the distinction between research and
practice-focused doctorates. According to their statement,
Graduates of both research and practice based doctorates
are prepared to generate new knowledge. However, research
focused graduates are prepared to generate knowledge
through rigorous research and statistical methodologies
that may be broadly applicable or generalizable; whereas,
practice focused graduates are prepared to generate new

50 Unit 1 The Evolution of Advanced Practice
and models of care probably has goals that are more in
alignment with the PhD. There is also the option of
completing both the PhD and DNP, either as a dual
degree or separately as ones focus evolves and different
methodologies are needed. Each can be completed as a
separate complementary degree that further builds on
the practice or research foundation of the other degree.
The important conclusion is that APNs have choices in
the selection of a terminal degree that best fits with their
goals as they advance their careers. In the long view, there
will probably come a time when all APNs complete the
DNP, which then will form the foundation for all PhD
students in nursing. Joint DNP/PhD degree programs
analogous to the MD/PhD now exist at Barnes/Jewish
College of Nursing in St. Louis, University of Tennessee
Health Sciences Center, and Case Western Reserve
University in Cleveland. Looking forward, the PhD as
a sequel to the DNP may in fact become a reality for the
profession in the long view.
Moving forward, there are important strategic implications for the nursing profession with the rise of the DNP.
PhD programs optimally will attract those who are serious
about their interest and passion for research, which will
ultimately have the outcome of a more highly engaged
scientific cadre of nursing scholars. Clearly complementary scholarship that includes PhD and DNP students on
the same team will serve to advance nursing science and
practice to the next level.
Health Science Center along with medicine, pharmacy,
clinical, and rehabilitative health sciences and public
health, who each have a longstanding commitment to
interprofessional education (p. 313). Their project provides
an excellent example of the catalytic synergy that can take
place when the strengths of DNP and PhD education
are brought together. Table 4.1 contains examples of
complementary residency experiences in the DNP and
PhD programs (p. 317).
As these common and complementary areas illustrate, there is much to be gained from the strategic
collaboration between PhD and DNP students. Within
the right context, this collaboration will continue to
develop beyond graduation to advance nursing science
and evidence-based practice in innovative ways. Combining PhD and DNP resources will translate and deliver
best practices to the patient as never before envisioned.
Partnerships between DNP and PhD students selected
for the natural synergy of their dissertations and DNP
projects would greatly speed the educational process,
generate publications, and produce other outcomes that
are both useful and fundable.
As to whether the DNP or PhD degree is the best
option or fit for an individual APN, it is more about an
individuals professional goals. The APN who is focused
and immersed in clinical practice is probably best advised
to seek the DNP degree, whereas the APN who is passionate about research and testing innovative interventions
Table 4.1
Complementary Residency Experiences in the DNP and PhD Programs
PhD Research Residency Activities DNP Practice Residency Activities
Literature review in area of nursing science Literature review of evidence in nursing
Pilot research projects for dissertation Participation in quality improvement
Participation in full scope of research Development in capstone with mentors
Presentation at research conferences Presentation at practice conferences
IPE (interprofessional education) collaborative experiences IPE collaborative experiences
Submission of research grant proposals Submission of practice or leadership grant proposals
Participation to influence health policy Participation to influence health policy

Chapter 4 Educational Preparation of Advanced Practice Nurses 51
business schools have come under intense criticism for
failing to impart useful skills and instill norms for ethical
business behavior. Similar to business, in academia nursing
finds itself trying to replicate the academic and scientific
traditions of fields such as chemistry and history. This is
especially common when PhD faculty have left clinical
nursing practice perhaps even decades earlier. The mission
to educate the doctoral-prepared practitioner or scholar
seems to have been lost to create the proper nurse scientist.
Nursing science that contributes critical, high-impact
translational health research can distinguish the profession
of nursing, raise credibility, better position the discipline
within the community of science, and movethesciencefrom
bench to bedside. At present, nursing research lacks wide
recognition and receives limited grant-funded support. In
2015 the National Institutefor Nursing Research received
$145,912,000 in funding; although at first glancethis number
appears to be a robust allocation, it represents thelowest level
of funding of any institute within the National Institutes of
Health (NIH). In 2015 the NIH received a total budget
of $4,300,145,614; that leaves nursing with less than 1%
of the NIH budget. In 2014 575 applications werereceived
by the National Institutefor Nursing Research but only 46
were awarded funding. In 2014 nursing achieved an overall
success rate of 8%, which is the lowest of any institute or
center within the NIH (NIH Research Portfolio Online
ReportingTools, 2015). Nurseresearchers conduct studies
that are key to the management of chronic disease, health
promotion, and end of life care. In order to increase the
funding allocation for the NINR, nursing research needs
to be better understood by the public with translational
research projects conducted in tandem to demonstratethe
importance of our work. I believethat in concert the DNP
and PhD graduate can make this happen.
Given the move by the government to fund more
interdisciplinary translational research, the need for
well-trained nurse scientists is more apparent than ever
(National Academy of Sciences, 2005). Nurse scientists
and researchers should not confine their research efforts
to those funded solely by the NIH and other government
agencies; rather, they should also seek private sector foundation funding. The bar is very high, however; with the
growing enrollment in PhD programs and the extremely
robust enrollment in DNP programs, a critical mass of
expertise is being created that will have a measurable impact
on the advancement of nursing science.
The PhD in Nursing: The Future Is Bright
AACN data from 20042014 (AACN, 2016, p. 7) reveal
that there has been an increasein research doctoral program
enrollment from 3,715 in 2005 to 5,290 in 2014 with
steady incremental increases in enrollment each year. In
contrast, DNP enrollment has increased from 269 students
in 2005 to 18,352 in 2014. These strong numbers bode
well for the nursing profession with a clear focus on the
future of health care and how we can achieve the greatest
difference. These numbers also clearly indicate that the
DNP is not diverting applicants from PhD programs,
which are continuing to grow in enrollment to almost
nearly double what they were in 2005 before the DNP
took hold.
The DNP and the Faculty Role
In 2006, the AACN stated that DNP graduates are not
prepared for the full scope of the faculty role without
additional education and supervision (McKenna, 2005;
Wittmann-Price, Waite, & Woda, 2011). Lack of preparation for the faculty role is a problem that is also evident
for recent PhD graduates, especially if they have had little
or no previous teaching experience. The exception involves
recent graduates of PhD programs in Nursing Education
such as those at Villanova University and the EdD program at Teachers College, Columbia University. For new
graduates of DNP and PhD programs alike, deans need
to provide support systems that include senior faculty
mentors with the understanding that the new DNP or
PhD graduates are novices in need of support to succeed
in all the dimensions of the demands of the faculty role.
Although there has been an increase in the number of
new PhD in Nursing programs during the past decade,
there has been limited support to properly socialize and
mentor doctoral students in the nursescientist role, leaving
many unprepared for the rigors of conducting postdissertation research (Dreher & Smith Glasgow, 2011; Potempa,
Redman, & Anderson, 2008). This is a criticism widely
proffered by the University of Washingtons project on
Re-envisioning the PhD (Nyquist & Wulff, 2000). Similar
commentary is found in How Business Schools Lost
Their Way from the Harvard Business Review (Bennis &
OToole, 2005). The parallels between business education
and nursing are striking. For almost a decade, professional

52 Unit 1 The Evolution of Advanced Practice
Health-care reform within the context of the PPACA
(2017) has enabled many previously uninsured individuals to gain access to health care, increasing the demand
for primary and tertiary care services that will ultimately
increase the demand for NPs and primary care physicians.
This creates a strategic opportunity for APNs to step up
to the needs of society and practice to the full extent of
their educational preparation. Attainment of the DNP
as the new standard will serve to bring APNs to their
rightful position as an equal partner on the interprofessional health-care team. In order to achieve this goal of
parity with the major health professions, APNs need to
unify and strategize to advance to the next level. APNs
have the potential to be leaders in the delivery of primary
care because physicians are more typically attracted to
specialty practice. Using the DNP as entry for advanced
practice is a reasonable expectation and goal, which will
support excellence in patient care with vastly improved
clinical outcomes.
SUMMARY: A NEw Vision For the
As APNs, specialty organizations, and other stakeholders
consider the implications of the AACN 2015 goal, some
suggestions for thefuture of nursing education for advanced
practice are offered. Although the 2015 goal for transition to
the DNP forentry into advanced practice has passed, there
is mounting dynamic movement within the profession to
move to the next level. With more than 18,000 currently
enrolled DNP students, change is occurring within the
profession at a fast pace never before experienced. With
NONPF endorsing the movement to the DNP for NPs,
we are at the crossroads, beginning transformation in the
education of APNs.
In order to achieve parity with other major health
professionals, the education of APNs must equip them
with competencies that hold some level of extra value in
addition to the MD and the other major health professions.
Quite evident is the clinical research skill of the DNP
graduate, which focuses on translational evidence-based
projects along with those that focus on patient safety
issues that will clearly place the DNP-prepared APN in
key leadership positions. Beyond that, the DNP-educated
nurse possesses skills in the understanding and advancement
Settling the Dust Between the DNP
and the PhD
New doctoral programs in any discipline are not created
without in-depth analysis. Additional resources or the reallocation of resources from other academic programs often
will be needed. At this time, the majority of universities
that offer the PhD in Nursing also offer the DNP. Over
the past decade, substantial enrollment increases have
occurred in both DNP and PhD programs.
With the advent of the DNP, it is risky for the profession
to rely solely on nursing PhD graduates to advance the
science. There is much to be accomplished through the
collaborative efforts between the DNP and PhD graduates
who will work together to advance translational research
projects, bringing the bestevidence-based practiceto patient
care. OSullivan and colleagues (2005) rightly raise the
argument that because many PhD graduates never conduct
research past their dissertation, these students might have
been better served by a practice doctorate option. The DNP
option now enables those who are clinically immersed
in their passion for practice to improve practice through
evidence-based projects.
The Advanced Practice Nurse With an MSN,
DNP, or PhD
Luther Christman, a leader and visionary in nursing
(19152011), proposed through the Rush Unification
Model for nursing that all nurses have advanced education
to practice. His Unification Model incorporated interprofessional teams composed of physicians, nurses, and other
health professionals practicing together for the benefit of
patients. Christman (Pittman, 2005) was the dean and vice
president of nursing at Rush-Presbyterian University Medical
Center in Chicago. Education, practice, and research were
evident on every nursing unit (Pittman, 2005). Christman
believed that nursing was poised to achieve parity with
medicine and other health professionals if all possessed
terminal degree credentials. Although health-care delivery
has changed dramatically since Christman articulated his
vision of a Unification Model, certain elements remain
constant. It is now well understood that no one profession
can provide holistic comprehensive interprofessional care
where health professionals work collaboratively to ensure
the best patient outcomes.

Chapter 4 Educational Preparation of Advanced Practice Nurses 53
evidence (p. 173). How do new DNP programs really
effect change because of their curricula beyond the scope
of the MSN? One of the challenges with the wide array of
DNP programs has to do with its unevenness with regard
to skills, knowledge, and competencies beyond the MSN.
As more and more DNP programs become accredited by
either CCNE or CNEA, these differences should become
somewhat diminished with firmer standards emerging.
As the number of DNP graduates increases, programmatic evaluation data will be generated to identify how
these graduates are making a difference. It is likely that
MSN preparation will continue for a time; however, as
outcome data are generated we will be able to measure
the difference that the DNP makes, which will hopefully
fuel the transition to full acceptance of the DNP as the
new standard of education for APNs. As we look to the
future, and hold on, the best is yet to come for the nursing
profession and patients alike.
of health-care system issues, which with the PPACA are
on the forefront and cutting edge of health-care problems
to be solved.
In 2005, Broomeidentified two serious issues that nursing
still faces today: an urgent need for more BSN-prepared
nurses and a severe nursing faculty shortage that is only
going to escalate in the decade to come. Discussion of the
DNP for advanced practice students cannot be separated
from a discussion about what type of academic preparation
is best to teach them. Mundinger (2005) of Columbia
University has described the ways in which the doctoral
role of advanced practice differs from MS-level practice.
She emphasized that the DNP graduate shows a greater
depth and breadth of knowledge and practice with significant additional science education provided by courses
in genetics, advanced pathophysiology, pharmacology,
differential diagnoses, chronic illness, bioinformatics,
research methods, and identification and use of medical

Global Perspectives on Advanced
Nursing Practice
Madrean Schober and Anna Green
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Identify the growth of advanced nursing practice (ANP) worldwide.
Demonstrate issues influencing the development of advanced practice nursing globally.
Illustrate the impact of the International Council of Nurses (ICN) in setting
international standards.
Compare country illustrations of growth and progress of advanced practice nursing.
Detail controversial practice issues and challenges faced with emerging roles.
Distinguish the diversity of international health-care systems.
Contrast the lack of role clarity and international consensus on the meaning of ANP.
There is growing international recognition that advanced
nursing practice(ANP)*should be developed, acknowledged,
and legitimized. Factors contributing to a greater willingness to explore ANP options are multifaceted. Physician
shortages, increased demand for highly specialized nurses, a
greateremphasis on primary health care(PHC) and homebased services, and the increased acuity and complexity
of hospitalized patients are among the issues motivating
decision makers to rethink provision of health-care services (Buchan et al, 2013; Delamaire & LaFortune, 2010;
DiCenso et al, 2010; Sastre-Fullana et al, 2014; Schober,
*Advanced nursing practice (ANP) is used as a comprehensive umbrella
term for the discipline or function of APNs. The term advanced practice
nurse (APN) is used in reference to APN roles, APN practice, APN curriculum, APN positions, or individuals who are APNs.

Chapter 5 Global Perspectives on Advanced Nursing Practice 55
to country context that could be effective in influencing
optimal practice for ANP (Maier, 2015).
This chapterexamines some of theissues influencing the
development of ANP globally. Theemergence of the rolein
different regions of the world, the role of the International
Council of Nurses (ICN) in setting international guidelines,
and some of the controversial practice issues affecting the
nature of ANP are explored. Country illustrations provide
examples of growth, progress, governance, and challenges
experienced worldwide.
The International Nurse Practitioner/Advanced Practice
Nursing Network (INP/APNN) was launched in 2000
under the auspices of ICN to follow trends and act
as a resource for ANP. Following the initiation of the
2016). Professional factors for nursing are also influencing
developments in this field. The acquisition of more highly
developed qualifications as nursing education moves into
the academic education sector is matched by a demand
for clinical career ladders or pathways that acknowledge
professional advancement and give nurses an incentive to
remain in clinical practice (De Geest et al, 2008; ICN,
2007; Schober, 2013, 2016; Zurn, Dolea, & Stilwell, 2005).
The predicted global deficit of 12.9 million physicians,
nurses, and midwives by 2035 has stimulated a renewed
examination of skill mix including options for introducing
new types of health-care workers; these options include task
shifting, task reallocation, and theexpansion of current roles
of all health-care professionals (WHO, 2014). Historically,
Buchan and Calman (2005) identified several drivers in
health systems in countries belonging to the Organization
for Economic Co-operation and Development (OECD)
contributing to a heightened interest in the advanced
practice nurse (APN) role. In addition to staff shortages
faced by these countries, these authors suggested that
health sector reform and new initiatives have stimulated
serious consideration of the appropriateness of current
role definitions for health-care workers and skill mix.
Aspects affecting these deliberations include cost containment measures, actions to improve service quality,
the introduction of technological innovations and new
therapeutic interventions, and alterations in the legislative
and regulatory environment. The growing body of literature
continues to confirm this diversity in motivation globally
when countries consider the option of advanced nursing
roles (De Geest et al, 2008; Delamaire & LaFortune,
2010; Schober, 2016). See Box 5.1 for a summary of
factors contributing to ANP growth.
However, enthusiasm and motivation when redefining
roles for health-care professionals is not enough to support
a strong climate of advocacy for these changes (Buchan
et al, 2013). Continuing clarity on who the advanced
nurse is and the place of an advanced nursing role in the
health-care workforce are themes that take center stage
in the evolving international drama of development. The
World Health Organization (WHO) in its continued
efforts to maximize the capacities and potential of nurses
and midwives emphasizes the need to mobilize political
will to build effective workforce development (WHO,
2016). The maturing nature of the discipline calls leaders
and decision makers to assess models of governancespecific
Escalating disease burden worldwide: communicable
and noncommunicable diseases
Increased inpatient acuity and complexity of treatment
Impact of technological innovations and new therapeutic approaches
Increased emphasis on PHC and community-based
Increasing requests for and complexity of homebased care
General global shortage of health-care workers stimulating consideration of skill mix, task-shifting,
and task reallocation options
Physician shortages
Increased demand for specialized nurses
Nursings desire for a clinical career ladder and
professional advancement
Better-informed health-care consumers
Intensified demand for options to address out-of-control
health-care costs
Search to improve quality of and access to health-care
Box 5.1
Factors Contributing to International
Growth in Advanced Nursing Practice

56 Unit 1 The Evolution of Advanced Practice
INP/APNN ICN consulted extensively with members
of the network to reach a consensus on the definition,
characteristics, and scope of practice for an APN.
Because of this consultation ICN provided the following
definition (ICN, 2008b):
a registered nurse who has acquired the expert knowledge base,
complex decision-making skills and clinical competencies for
expanded practice, the characteristics of which are shaped by
the context and/or country in which s/he is credentialed to
practice. A masters degree is recommended for entry level.
See Table 5.1 for ICN-recommended role characteristics.
Although ICN does not specifically define the scope
of practice, it draws on the definition and characteristics
described in Table 5.1 in recommending that countries
should keep the following points in mind when developing
a scope of practice for the APN:
Requires cognitive, integrative, and technical abilities
to put into practice ethical and culturally safe acts,
procedures, protocols, and practice guidelines.
Has the capacity for delivery of evidence-based care in
primary, secondary, and tertiary settings in urban and
rural communities.
Practices a high level of autonomy in direct patient
care and management of health problems, including
case management competencies.
Accepts accountability for providing health promotion,
patient and peereducation, mentorship, leadership, and
management of the practice environment.
Maintains current nursing practice and seeks improvement through the translation, use, and implementation
of meaningful research.
Engages in partnerships with patients and health
team members for determining resources needed for
continuous care and partnering with stakeholders in
influencing policies that direct the health-care environment (adapted from ICN, 2008b, p. 13).
Core competencies have been identified and published
in the following ICN documents: The Scope of Practice,
Standards and Competencies of the Advanced Practice Nurse
(ICN, 2008b) and Nursing Care ContinuumFramework
and Competencies (ICN, 2008a). Since the time that ICN
developed these guidelines, additional competencies have
emerged as prominent aspects of the role. As the field of
ANP has matured, the nurse in an APN roleis often seen as
Table 5.1
International Council of Nurses Characteristics for the Advanced Practice Nurse
Educational Preparation Nature of Practice
Regulatory Mechanisms
(Country-Specific Regulations
That Underpin Advanced
Practice Nursing Practice)
Educational preparation at an advanced
The ability to integrate research,
education, and clinical management
Right to diagnose
Authority to prescribe medications and
Formal recognition of educational
High degree of autonomy and
independent practice
Case management
Advanced assessment and decisionmaking skills
Authority to refer to other professionals
A formal system of licensure, registration,
certification, or credentialing
Recognized advanced clinical
The ability to provide consultant services
to other health professionals
Recognized first point of entry for services
Authority to admit to hospital
Title protection
Legislation specific to advanced practice
International Council of Nurses. (2008b). The scope of practice, standards and competencies of the advanced practice nurse. Geneva: Author.

Chapter 5 Global Perspectives on Advanced Nursing Practice 57
conference(Affara, 2006). Issues surfacing weresimilar to
those uncovered by Schober and Affara (2006) from their
survey of key informants and theliterature, published and
unpublished, on the status of ANP internationally.
An ICN survey of 32 countries conducted in 2008
provided additional confirmation of the expansion of NP
and APN roles internationally while also highlighting some
of the challenges encountered (Pulcini et al, 2010). At the
2011 ICN Congress in Malta, Roodbol (2011) reported
that membership in the ICN International NP/APNN
represented 78 countries with an interest in ANP. As ofJune
2016 ICN reported that membership in the INP/APNN
included representation from 94 countries (A.Canedo, personal communication,June 9, 2016).The numbers based on
INP/APNN membership as of 2011 and 2016 suggest an
interest in exploring the concept of advanced nursing roles but
do not necessarily represent an active presence of APN roles.
Development and implementation of APN roles is fraught
with difficulties even when there is enthusiasm to integrate
this new category of nurses into the health-care workforce.
The following section identifies some of the key challenges
in role development and realization of the ANP concept.
Role Ambiguity and Lack of Role Clarity
Role ambiguity and lack of role clarity is related to an
inability to define a scope of practice for the APN and what
this nurse will do in the health-care workforce (Donald
et al, 2010; Gardner et al, 2007; Schober, 2016). In the
absence of a clearly defined scope of practice, it is difficult
to delineate accountability and responsibility. In addition,
the lack of a defined identity affects the ability of APNs to
communicate clear messages about the nature of their role
to clients, policy makers, other health-care professionals,
regulators, and educators, among others.
Findings from theCanadian Decision Support Synthesis
on Clinical Nurse Specialists and Nurse Practitioners in
Canada further indicatethat regulators,educators, government officials, and administrators consistently raised concerns
regarding thelack of clarity surrounding APN roles and the
potential of losing the role during economic downturns or
when other roles are introduced if the contributions of the
APN role were not clear (DiCenso et al, 2010).
a clinicalexpert with characteristics of the role crosscutting
over numerous themes that includeincreased understanding
of issues of governance, policy development, leadership, and
research (Schober, 2016). This developmental issue along
with the varying nature of the discipline globally suggests
that a review and revision of international competency
guidelines defining the APN is needed.
Progress in this direction has been initiated by Bird and
Schumann (2016) in their 2014 survey of 16 countries that
identified competencies for APNs. This survey provides
a comparison of the Strong Model of Advanced Practice
Nursing (Ackerman et al, 1996) and the ICN APN competencies (ICN, 2008b) with APN competencies provided
from respondent countries. As of July 2016 the data are
being analyzed with publication of findings expected in
2017 (B. Bird & L. Schumann, personal communication,
June 30, 2016).
Following 16 years acting as an internationalresourcefor
ANP presence globally and a changein ICN administration,
the ICN in July 2016 reviewed the functionality of their
nine networks including the INP/APNN. Further, at the
ICN 2017 Congress in Barcelona, Spain theformation of a
Global Alliancewas announcedwith theintent of broadening
ICN access to international resources. The ICN NP/APN
Network will bethe prototypefor this concept leading with
the development of a resource clusterfor APNs.It isexpected
that ICN will continue to follow ANP trends and development with theintroduction of a new organizational model.
Since the 1990s the ICN has monitored the progress of
ANP globally. In 1999, in responseto an ICN survey sent to
125 nation members, 33 countries reported having nursing
roles with advanced practice elements (Schober & Affara,
2006). In a follow-up survey, Roodbol (2004) reported
that 60 countries indicated an interest in ANP or were in
the process of developing advanced practice roles.
Information on thestate of ANP globally and associated
developmental issues was obtained from a Strength/Weakness/
Opportunities/Threats (SWOT) analysis carried out with
participants attending the 2006 ICN APNN Conference
in the Republic of South Africa. This analysis highlighted
important areas of concern affecting the evolution of
ANP in many of the participating countries attending the

58 Unit 1 The Evolution of Advanced Practice
(2005) found thateven though physicians believed that the
APN presence had a positive effect on the social identity
of nurses in general, nurses as a whole did not share this
view and were not prepared to accept them into their
professional group.
Varying Levels of Autonomy
The degree of autonomy afforded to APNs varies from
country to country and even within the same country.
This appears to be related to the degree of recognition
and acceptance of the role and to the type of regulatory
mechanisms in place (Schober, 2016).
Variable Standards and Quality
of Education Programs
Historically and up to the present time,educational qualifications for the APN role have varied from the awarding of
certificates for postbasic or baccalaureate courses of various
lengths to undertaking a formal university program and
obtaining a masters degree. Information from an ICN
INP/APNN survey indicated that among 31 responding
countries, 50% replied that the most prevalent credential
was the masters degree (Pulcini et al, 2010). Education
and preparation beyond the level of the generalist nurse is
a critical component in the development of the APN role.
TheICN guidelines suggest thatentry-leveleducation at the
masters level should be a recommended goal (ICN, 2008b).
See Box 5.2 for theICN-recommended education standards.
Professional Regulation, Credentialing,
and Standard Setting
Standards, supportive legislation, and professional regulation ultimately provide the underpinnings for successful
ANP implementation and sustainability. Development of
appropriate policies, although essential, can contribute to
intense discussions and lengthy debate. Thelag between actual
APN practice and supportive legislation can be attributed
to uneven starts in initiating new roles and the diversity of
health issues challenging the communities and countries
where these roles seek to grow. Also, restrictive regulations
that unnecessarily limit theexpertise and scope of practicefor
APN roles can considerably affect to whatextent advanced
practice will beembraced by a health-caresystem and permit
Proliferation of Titles
Identification of ANP globally is plagued by a proliferation
of titles. This diversity leads to confusion and lack of understanding as researchers attempt definitive research and
regulators look for guidance when developing professional
regulation. In addition, functions and responsibility vary
considerably from one setting to another even when one
title is used within the same country (Pulcini et al, 2010;
Schober, 2016). This lack of consensus adds to the mystery
as to what titleshould be applied as distinctive rolesemerge
in countries in the early stages of role development.Titles
currently being used throughout the world include nurse
practitioner (NP), family NP (FNP), adult NP, advanced
NP, primary care practitioner (PCP), clinical nurse-midwife
(CNM), clinical nurse specialist (CNS), nurse anesthetist
(NA), community health NP (CHNP), and womens health
NP (WHNP). Pediatric NP, gerontological NP,emergency
room NP, and acute care NP are also titles applied to APN
roles. Some titles indicate the specialty of the APN; other
titles have been developed to fit the context of the systems
or the situations in which the APN role exists. The ICN
survey of 32 countries discovered 14 different titles being
used to designate ANP (Pulcini et al, 2010). The variety
of titles being used reveals the explorative nature and
diverse perspectives of advanced practice internationally
with respect to the parameters of the role and where it
sits in relation to other nursing and professional roles in
the health-care system (Schober, 2016).
Lack of Recognition by Other Professionals
in the Health-Care System
Medical dominance and control over the provision of
health-care services,especially in more developed countries,
are cited as major obstacles to implementing APN roles.
In addition, scope of practice conflicts and overlap with
other health professionals scope of practice, especially
medicine, contributes to APNs feeling unwelcome within
the health-care team. Interestingly, one of the particular
problem areas revealed by research conducted in Singapore
by Schober (2013) was a mistrust that may exist between
APNs and other nurses. Schober and Affara (2006) had
uncovered a similar sentiment in information obtained
from key informants who reported obstacles to the role
arising from other nurses. In the Netherlands, Roodbol

Chapter 5 Global Perspectives on Advanced Nursing Practice 59
Programs preparethestudent, a registered/licensed nurse,
for practice beyond that of the generalist nurse by
including opportunities to access knowledge and
skills, as well as demonstrate their integration in
clinical practice as a safe, competent, and autonomous practitioner.
Programs prepare the authorized nurse to practice
within the nations health-care system to the
full extent of the role as set out in the scope of
Programs are staffed by faculty who are qualified and
prepared at or beyond the level of the student
undertaking the program of study.
Programs are accredited or approved by the authorized
national or international credentialing body.
Programs facilitate lifelong learning and maintenance
of competencies.
Programs provide student access to a sufficient range of
clinical experience to apply and consolidate under
supervision the theoretical course content.
Box 5.2
International Council of Nurses Standards for Education of the Advanced Practice Nurse
International Council of Nurses. (2008b). The scope of practice, standards and competencies of the advanced practice nurse. Geneva: Author.
APNs to contribute to their fullest capacity. A process of
evaluation and revision of professional regulation may be
the only option to follow when regulations are found to
hinder optimal professional practice. This, in turn, poses
another set of challenges as to who has the authority to
initiate and the power to supply leverage in provision of
solutions in the credentialing and regulatory arena.
National nursing associations and nursing leadership
would seem to provide the likely foundation for development and exploration of educational requirements and
standards,especially becausethe core of ANP is grounded in
nursing theory and nursing science. However, there appears
to be a lack of consensus among nursing academics and
leaders as to what ANP really means, and at times overt
support by nursing bodies is lacking as the roles develop.
Key decision makers and advisors have begun to provide
regulatory and credentialing guidance and make policy
decisions. International organizations, such as the ICN,
are taking official organizational positions regarding ANP
and offer publications (ICN, 2008a, 2008b) to facilitate a
better understanding of ANP. Box 5.3 identifies the minimal regulatory standards recommended by ICN (2008b).
Flexible regulatory language has been encouraged to
ensure quality health-care services that are protective of the
populations receiving thoseservices. However,especially in
countries that are newly developing standards, restrictive
regulatory legislation affecting APNs is promulgated to
protect the practice of other health-care professionals.
Develop and maintain sound credentialing mechanisms that enable the authorized nurse to practice
in the advanced role within the established scope
of practice.
Establish relevant civil legislation or rules to acknowledge
the authorized role, monitor the competence, and
protect the public through issuance of guidance,
assessment processes, and, when necessary, fitness
to practice procedures and processes.
Periodically revise regulatory language to maintain
currency with nursing practice and scientific
Establish title protection through rule making or civil
Box 5.3
International Council of Nurses Minimal Standards for Regulating the Advanced Practice Nurse
International Council of Nurses. (2008a). Nursing care continuumframework and competencies. Geneva: Author.

60 Unit 1 The Evolution of Advanced Practice
question underlying the topic of nurse prescribing is not
Can nurses prescribe? in a particular country, but To
what extent is nurse prescribing established? How nurse
prescribing evolves and becomes an integral part of the
health-care system is as important as whether or not nurses
have the legal authority to prescribe.
Nurse prescribing prototypes internationally provide
models by which nurses may potentially be involved in
prescribing (Ball, 2009). Nurse prescribing is not always
associated with ANP as evidenced by countries or regions
with authority for nurses to prescribe. Sweden, Australia,
Canada, New Zealand, and countries of the United Kingdom
(UK) have well-established community nursing or general
nursing roles supportive of this capability.
In appraisal of the key global issues associated with
nurses prescribing, Ball (2009) indicates that there is
little uniformity as to what role nurses should have with
regard to prescriptive authority. Educational programs to
prepare nurses for prescribing range from masters degree
preparation to a designated program of a few study days.
Although these issues are varied, there are common approaches when considering nurses prescriptive authority.
These include the acceptability of nurse prescribing within
the health-care setting, designation of which nurses will
prescribe, and strategies for implementation and feasibility
from an administrative and health policy perspective. The
differences between countries reflect differences in healthcare systems, the population demographics of the country,
and the status of nursing (Ball, 2009).
The development of ANP internationally has progressed
significantly in numerous regions of the world. To review this global growth, examples are presented from
diverse experiences of countries introducing, developing,
and implementing APN roles. To grasp perspectives of
emerging development, country illustrations are arranged
according to WHO-designated regions. Descriptions of
country progress and interpretation of ANP are intended
to provide representative examples of a region but are not
meant to portray all activity in any one area of the world.
The authors acknowledge that wherever the concept or
level of ANP arises the occurrence of this phenomenon
Clarity and consistency in defining the process and
structure of credentialing for APNs and accreditation of
educational programs is essential as the APN investigates
intercountry choices foremployment and educational opportunities. Professional mobility may potentially shape a
movetoward consensus for credentialing among countries as
APNs relocate, immigrate, or accept temporary assignment.
The capability of agencies and organizations in addressing
legislative issues, standards, and professional regulation
will increasingly come under scrutiny as the international
nursing community looks for authoritative guidance.
In ANP development and implementation, professional
regulation often needs to catch up with innovation if understanding and confidence in the role is to be established
for the benefit of key decision makers, the profession, and
the public. However, the setting up of suitable regulatory
mechanisms needs to be approached in such a manner
that new problems are not created, health-care systems
are not made less efficient, or access is reduced to those
who benefit by APN services.
Authority to Prescribe Medicines
and Therapeutics
Nurse prescribing of medicines or therapeutics describes
various types of nursing practice currently undertaken in
different countries or regions of the world. In general,
discussion of this issue focuses on the suitability of prescriptive authority for nurses and the appropriateness of
nurse prescribing as it relates to defined characteristics
and expected competencies for APN roles. Nevertheless,
discourse and comment reveal that nurses have been
prescribing medicines, treatments, and other therapies
in certain health-care settings, but the reality of carrying
out these activities within a legal framework and in a
supportive health-care environment, such as one that
has enabling workplace policies in place, lags behind the
requisites of actual practice. However, as more countries
implement APN roles in a variety of settings, the issue of
nurse prescribing is becoming less of a controversial issue.
It appears that advancement for APN and NP roles
necessitates prescriptive authority, but it is worth noting
that health-care services in some areas of the world havefor
sometimeincluded nurse prescribing of a range ofessential
drugs at the first level of practice in primary health-care
systems (Ball, 2009). Ball (2009, p. 67) suggests that the

Chapter 5 Global Perspectives on Advanced Nursing Practice 61
have a diploma in general nursing (G.N.) with a minimum
of 2 years service as a general nurse, be registered as a
general nurse with the Nursing and Advance Diploma in
Midwifery Council of Botswana, and be in possession of
a Botswana General Certificate of Secondary Education
(BGCSE) or its equivalent.
Because the University of Botswana now offers a
masters degree in nursing science with the option for
FNP study, a comparative analysis of the masters degree
and FNP curricula at IHS is underway to identify how
the two programs could combine common coursework
and remove redundant or repetitious study while still
supporting educational advancement for the FNP
educated in the IHS program. Possibilities for credit
transfer and opportunities for challenge examinations
or applying for exemption from retaking courses when
seeking further study at the University of Botswana are
being considered (C. Pilane, personal communication,
August 14, 2014).
NPs in Botswana provide primary care in outpatient
departments, clinics, industry, schools, and private practice
throughout the country. The health-care environment in
Botswana supports autonomy in provision of PHC services
as evidenced in nurse-managed facilities and prescribing
privileges. Challenges are lack of specific regulations, the
absence of clear qualifications, no designated career advancement for FNPs, and lack of availability of qualified
faculty for the educational programs. Study findings by
Seitio-Kgokgwe et al (2015) confirm issues associated with
lack of central coordination, weak leadership, weak policy
and regulatory frameworks, and inadequate resources
with a focus on the lack of attention to organizational
structure. The conclusion from this study is that there is
an opportunity for the Ministry of Health in Botswana
to reorganize and enhance the associated health-care
infrastructure in hopes that this would solidify support
for FNPs and nursing.
Republic of South Africa
The key challenges for NPs in South Africa liein lobbying
for enabling legislation, obtaining access to education and
training opportunities, and managing risks within therapidly
changing environment (Geyer et al, 2002, p. 11). Even
though this statement was madein 2002, the commentary
remains true today (N. Geyer, personal communication,
July 2, 2016).
is subject to specific health-care, nursing, and political
cultures. The dynamic authority of leaders within local,
national, and institutional settings ultimately drive policy
that impacts the APN role and the manner in which the
APN practices.
Africa: WHO-AFRO
The WHO Regional Officefor Africa is located in Brazzaville,
Republic of Congo. Personnel in the office include the
WHO regional committee for Africa, a secretariat for the
African region, three intercountry support teams, and
country and liaison staff located in 47 member states.
In Botswana, a poorly developed health-care system and
a severe shortage of physicians following independence in
1966 triggered the need for nurses with advanced skills
and decision making to provide services usually associated
with physician practice. Nurses accepted these increased
responsibilities but demanded furthereducation to enhance
their ability to meet the health-care needs of the country.
The Ministry of Health, through the Institute of Health
Sciences (IHS), responded by establishing the first FNP
diploma program in 1981 with the aim to educate nurses
in advanced skills in diagnosis and management of PHC
problems common in Botswana. The program evolved to
18 months of postbasic education in 1991, followed by a
revision and update in curriculum in 2001 with increased
emphasis on comprehensivefamily health services (National
Health Insurance [NHI], 2002). In 2007, a four-semester
format was introduced (Pilane et al, 2007). Currently,
the diploma programs at IHS are at an advanced stage
of curricula revision and upgrading to degree levels. At
the same time the masters program at the University of
Botswana is being revised and is likely going to address
articulation and recognition of prior learning issues from
the IHS diploma program.
The University of Botswana offers a master of nursing science degree that includes specialization as a FNP
(University of Botswana, 2016). Although the University
of Botswana has begun to graduate FNP students, the
diploma program at the IHS simultaneously continues
to offer a FNP program at IHS Gabarone and Kanye
SDA College of Nursing (Institute of Health Sciences,
Botswanna, 2017). Candidates for the IHS program must

62 Unit 1 The Evolution of Advanced Practice
staff nurses, and auxiliary nurses while also providing
the basis for progression to specialist nurse and FNP
scopes of practice. The South African Nursing Council
has revised the qualifications framework for nurses in
alignment with changes in education legislation in the
country that transfers all nursing programs to the higher
education band. The specialist nurse has been described
in legislation, but not the FNP.
The FNP scope of practice overlaps with aspects of scopes
of practice for other health practitioners, such as physicians
and, in the case of medicines, pharmacists. Dispensing of
drugs falls under the pharmacists function, whereas the
control of drugs as associated with prescribing isexclusiveto
the physician, unless the practitioner or professional, such
as a nurse, has been authorized to prescribe by his or her
respective councils or regulatory bodies. Nurses are listed
as one of these professions (see numbered items 3 and 4 in
Box 5.4). A nurse who wishes to dispense medicines must
undergo a course accredited with the pharmacy council.
Application for a license to dispense medication is made
through the national department of health. The license
is valid for 3 years, after which reapplication is required.
NPs in RSA are mainly employed in the public health
sector at the provincial and local authority level. Nurses
and midwives provide the majority of health services, with
nurses identified as the first point of contact for preventive
health and minor ailments. With the growing need for
home-based care, resulting mainly from the epidemic proportions of HIV and AIDS, nurses and NPs areincreasingly
holding leadership and supervisory responsibilities for
other workers and volunteers in health-care systems. The
publication of the White Paper on NHI for the country
includes roles for NPs as well as contracting for private
practitioners that is said to include nurses. This is where
the NP can make a significant contribution.
Establishing collaborative practice in the RSA context
is fraught with difficulty because language contained in
separate practice acts and regulations governing practice
of each category of health-care professional poses a significant barrier. Health-care practitioners can employ each
other, but stipulations within regulations prohibit group
practice. Such limitations either discourage formation
of multiprofessional groups or require development of
involved legal contracts to bypass the rules. Conflict arises
when existing scopes of practice are seen to overlap with
other professions, thus contributing to lack of agreement
The move since 1994 from a mainly hospital-based
health-care service to increased emphasis on PHC and
community-based services increased the visibility of the NP.
The creation of a more unified health-care system, while
dealing with rapid change in the health-care environment,
posed challenges and opportunities for the primary clinical
practitioner (PCP). PCP has been used as a title for NPs
in the Republic of South Africa (RSA); however, with the
development and introduction of new qualifications post
2016, the title will become FNP.
The 2005 Nursing Act and its regulations call for
NPs to possess required competencies. Standards for the
education and training of nurses and midwives have also
been established. Basic preparation for FNPs followseither
acquisition of a 4-year diploma or 4-year degree for general nursing, midwifery, psychiatry, or community health
nursing followed by a specialization program in diagnosis,
treatment, and care. However, the rapid acceleration in
use of nurses in PHC services has resulted in FNPs that
have not received specialist education. Therefore, one of
the challenges is providing sufficient access to education
to ensure nurses in the FNP role have the required competence to provide high-quality care.
Thescope-of-practice regulations provided by the South
African Nursing Council in 1984 provided practice principles that support nurses and midwives to perform any
acts for which they have been trained (Geyer et al, 2002,
p. 13). The FNP scope of practice will be written in such
a way that it emphasizes the provision of comprehensive
clinical services such as the following:
Comprehensive assessment
Diagnosis of health and disease, especially diseases
common in the RSA
Treatment and management (pharmacological and
Referral to other professionals
Leadership and management
Health promotion and disease prevention
However, the legal framework for the FNP has not evolved
as rapidly as practice. As of July 2016 a new scope
of practice for nursing was approved and is awaiting
promulgation by the Ministry of Health. See the first
numbered item in Box 5.4. This scope will make a clear
distinction between the roles for professional nurses,

Chapter 5 Global Perspectives on Advanced Nursing Practice 63
supportive of the development of advanced nursing roles.
This situation has interfered with legislative support for
FNP practice and expanded nurse dispensing and prescribing (N. Geyer, personal communication, July 2, 2016).
Western Africa
The scope of practice for a NP in West Africa (WA) is very
similar to that of a NP role described in other countries
(Madubuko, 2016). However, even though more than
1,000 nurses have masters degrees, advanced education
is not recognized in the nursing register. All registered
nurses (RNs) possess a postbasic nursing education and
clinical training in midwifery (registered midwife [RM]).
Therefore, RNs have additional advanced education in at
least one specialty areafor instance, in the psychiatric,
perioperative, nurse education, orthopedic, gynecological,
thoracic, or pediatric field. The WA College of Nursing
has accredited the University of Benin Teaching Hospitals
School of Ophthalmic Nursing for an 18-month masters
degreefor ophthalmic NPs that is consistent with the global
NP movement. Hopefully, the nurses in WAwith time,
explanation, and lobbyingwill obtain official recognition
for advanced education and clinical practice.
A RN or RM is certified by national certification examination and provides direct PHC. Thescope of practiceincludes
obtaining a history, performing a physical examination,
diagnosing and treating common illnesses, performing illness
prevention screenings, and promoting health. Education
and counseling are provided in collaboration with other
health professionals. Health-carereforms havesupported an
interest for more relevant health-care services in WA, thus
providing an opportunity for RNs and RMs in NP-like
roles and other health professionals (Madubuko, 2016).
The Americas: WHO-PAHO
The Pan American Health Organization (PAHO) is part
of the United Nations system, serving as the Regional
Office for the Americas of the WHO and as the health
organization of the Inter-American System. The following
descriptions provide examples of successful and emerging
APN activity in this region.
The Canadian Nurses Association (CNA) continues to
provideleadership for the development and implementation
1. The scope of practice has been structured for
three categories of nurses within a framework of
professional-ethical practice, clinical practice, and
quality of practice. This lends itself to developing
a structured scope that progresses to the next levels
of specialist nurses and NPs.
2. Educational programs linked to this scope will
prepare staff nurses who will be independent/
autonomous practitioners able to plan and execute
comprehensive care for stable and uncomplicated
patients. Professional nurses can specializein a variety
of areas, including family nurse practice. A criterion
has been built in that no nurse can specialize until he
or she has a 2-year clinical experience (this includes
1 year of community service after completion of basic
training plus 1 additional year of clinical practice).
3. Although there is a new Nursing Act, the profession
has not managed to get rid of government control
regarding the authorization of nurses to prescribe.
Section 56 of the Nursing Act of 2005 places more
controls into the system; nurses will now be licensed
to prescribe and reapply for licensing.
4. Work is currently in process on regulations for nurse
prescribing. The thinking has been that there will
be three levels of prescribing where nurses will have
access to specified drugs to manage minor injuries
and diseaseslikely according to protocols. These
levels are
Staff nurse = level one
Professional nurse = level two
Specialist nurse = level three (only access for
specialist area)
Box 5.4
Developments for Nurse Practitioners in the Republic of South Africa
N. Geyer, personal communication, July 2, 2016.

64 Unit 1 The Evolution of Advanced Practice
in Recommendations of the Canadian Nurse Practitioner
Initiative Progress Report. Among the remaining challenges
to NP integration, continued advocacy was needed on
federal legislative or policy barriers (e.g., prescribing of
controlled drugs and substances, distribution of drug
samples, completion of medical forms for disability claims,
and workers compensation) (CNA, 2009b).
In 2016 CNA reported significant progress on several
recommendations of CNPI and overall evolution of the
NP role (CNA, 2016). NPs are now practicing in a wide
variety of settings and in various models of care. There is
expansion of their scope of practice as well as pan-Canadian
title protection, a common role description, and professional
liability coverage. In spite of this progress, there continues
to be federal and legislative barriers for distribution of
medical samples, medical forms for disability claims, and
workmans compensation (CNA, 2016).
CNSs in Canada are registered nurses who hold a
masters or doctoral degree in nursing and have expertise
in a clinical nursing specialty (CNA, 2009a). The CNS
role was introduced to respond to increased patient need, a
demand for nursing specialization, and to support nursing
practice at the point of care. The CNS role has been part
of the Canadian health-care system for more than four
decades (DiCenso, 2008); however, researchers in Canada
report that CNSs are not fully utilized. Because the title
is not protected, it is difficult to report accurately on the
presence of the CNS (Kilpatrick et al, 2013). In 2014,
514 self-reported CNSs were prepared at the graduatelevel
(Canadian Institute for Health Information [CIHI], 2015).
CNSs practice varies in each health-care jurisdiction
in Canada and the title clinical nurse specialist is used
inconsistently. The CNA led the development of the
first Core Competencies for the CNS in Canada (CNA,
2014). Roundtable discussion identified that the varied
use of the CNS role stems from confusion about what it
entails. Yet, there is significant evidence demonstrating
the positive contributions that CNSs make to the health
of Canadians (Canadian Centre for Advanced Practice
Nursing Research [CCAPNR], 2012).
Several tools have been developed to assist with the
implementation of Canadian ANP roles: the CNPI implementation and evaluation toolkit (CNA, 2006) and the
Participatory, Evidence-Based, Patient-Centered Process
for Advanced Practice Role Development, Implementation
and Evaluation (PEPPA framework [Bryant-Lukosius &
of ANP in Canada. In 1999, the CNA developed a framework for ANP that was subsequently revised in 2002 and
2008. The framework provides the following definition
(CNA, 2008, p. 5):
Advanced nursing practice is an umbrella term describing an
advanced level of clinical nursing practice that maximizes the
use of graduate educational preparation, in-depth nursing
knowledge and expertise in meeting the health needs of individuals, families, groups, and populations. It involves analyzing
and synthesizing knowledge; understanding, interpreting and
applying nursing theory and research; and developing and
advancing nursing knowledge and the profession as a whole.
According to this framework, it is the combination of
graduate education and clinical experience that allows
nurses to develop the competencies required in ANP
(CNA, 2008, p. 6). Core competencies are described
as essential to ANP with a list of competencies in four
categories, outlined in the framework as clinical, research,
leadership, and consultation or collaboration.
Nurses in Canada are regulated at the provincial or
territorial level. The only advanced practice nursing role
with additional regulation and title protection, beyond RN,
is the NP. NPs can autonomously make a diagnosis, order
and interpret diagnostic tests, prescribe pharmaceuticals,
and perform specific procedures within their legislated
scope of practice (CNA, 2009b, p. 1).
Theimplementation of the NP roleregained momentum
following an 18-month federally funded, CNA-led Canadian Nurse Practitioner Initiative (CNPI) conducted from
2004 to 2006. This initiative helped in the development
of a framework for the integration and sustainability of
the NP role in Canadas health-care system. Recommendations for practice, education, legislation, regulation, and
health human resources planning were provided because
of findings from the CNPI.
In 2009, the CNA consulted with stakeholders on the
progress made in meeting the recommendations generated
from the 2006 CNPI (CNA, 2006). The main purpose
of the consultation was to compile information on the
activities of governments, nongovernmental organizations,
and other stakeholders at thefederal and provincial levels in
relation to the CNPI recommendations. The consultation
process revealed that although morethan half of the actions
concerning the CNPI recommendations had been fully or
partially completed, several key actions remained ongoing. The findings of the consultation process are outlined

Chapter 5 Global Perspectives on Advanced Nursing Practice 65
support by other professionals, lack of resources, and
limited educational opportunities created frustration and
obstacles to professional development.
The location of the three Cayman Islands, situated in
the Caribbean Sea between Jamaica and Cuba, contributes
to the diversity, as well as the uniqueness, of commonly
seen conditions. Cuban refugees and rafters trickle in for
health screenings and health care, periodic care for prison
inmates is provided, and hurricane evacuation preparedness
isessential for the health centers. The tourist industry, with
visitors from more than 80 countries, requires the nurse
to be knowledgeable about trauma and injuries related to
deep sea diving (Slocombe, 2000). The Cayman Islands
continue to register APNs and NPs to work at facilities
on the islands (L. Joseph, personal communication,
June 22, 2016).
In 1973 the Nurses Association of Jamaica (NAJ) held
exploratory meetings with the minister of health (MOH)
to discuss the training of NPs in the country. The interest
in the NP concept came as a response to the shortage of
physicians needed to provide cost-effective health care
to the poor in rural and underserved areas. Following
these discussions, NAJ then submitted a proposal for the
establishment of a NP program that was accepted by the
MOH. In 1977 the first NP program came into being
under the joint auspices of the Ministry of Health and the
Department of Social and Preventive Medicine within the
Faculty of Medicine with the Advanced Nursing Education
Unit (ANEU) providing a director.
The Ministry of Health with ANEU administered
the program with the Department of Advanced Nursing
(DANE) later having responsibility for the curriculum. The
program was initially a certificate program. In keeping with
the Ying Task Force on Education and also with current
trends in nursing education worldwide, the program was
transferred in 2002 to the Department of Advanced Nursing
Education (now the University of the West Indies School
of Nursing [UWISON]) where it is being offered at the
masters degree level. Since the inception of the program
in Jamaica many NPs from other Caribbean countries are
educated at UWISON in Jamaica.
NPs in Jamaica have been providing nursing and
medical care to all age groups within the health-care
delivery systems and in communities since 1978. Most
DiCenso, 2004]). These tools serve as a structured and
practical guide in assessing the need and readiness for ANP
roles based on the population health needs of Canadians.
In 2010, DiCenso and colleagues published research titled
the Clinical Nurse Specialists and Nurse Practitioners in
Canada: A Decision Support Synthesis. Thereport provides
an understanding of the roles of APNs, the contexts in
which APNs are being used, and the health system factors
that influence the way in which advanced practice nursing
is being integrated into the Canadian health-care system.
Although there continues to be a lack of understanding
among health professionals and the public in relationship to
ANP in Canada, the professional and policy environment
in the country is generally receptive and progressively
integrating ANP roles into the health-care system. Policy
makers, decision makers, and nursing leaders continue to
work together to face challenges as they refine and coordinate what ANP means in terms of health-care services
(J. Roussel, personal communication, May 4, 2016).
Cayman Islands
The emergence of ANP services in the Cayman Islands
provides an example of how NP-like roles evolve and
develop in response to the needs of the people, as well
as within geographical circumstances. The initiation of
NP-like services started in 1930 with provision of care by a
local midwife to meet community health needs. Physician
services were scarce and conditions were primitive with
populations residing in remote locations. NP services
progressed with the official employment of a nurse experienced in midwifery and community health to provide
PHC. Comprehensive health-care services were provided
in homes, schools, and clinic settings (Slocombe, 2000).
Expansion of clinicalexpertise progressed rapidly during
subsequent years, with the nurse as the main health-care
provider on the islands. The nurse diagnosed, treated,
prescribed, and dispensed what was viewed as necessary.
Conditions receiving care were whatever walked in through
the door (M. Slocombe, personal communication, 2002).
Immunization, antenatal, well-baby, nutritional, diabetic,
and hypertensive clinics were held, with backup consultation and collaboration provided by phone call to the
nearest hospital or by appointment with periodic visiting
physicians. The nurse took on the multifaceted role and
duties of counselor, administrator, staff supervisor, health
educator, accountant, and secretary. Absence of adequate

66 Unit 1 The Evolution of Advanced Practice
was to develop strategies for the implementation of the
APN roles in Latin America in order to address gaps in
health services and unmet population needs, changes in
nurses roles and responsibilities that can leverage APN
expertise, and factors that might enable these changes in
nurses roles and responsibilities (PAHO, 2015, p. 4).
Five planning priorities were identified from the 2015
PAHO summit. They are:
Establish masters level APN education programs
Engage and influence decision makers, legislators, and
other key stakeholders
Focus on APN service delivery for underserved populations with high needs
Establish a Pan American collaborative network to
develop and implement the APN role
Define and optimize complementary RN and APN
roles in new models of primary health care (PAHO,
2015, p. 9)
A draft plan was created for each priority with 1-year
(April 2016) and 3-year (April 2018) steps toward
implementation identified. These planning priorities
were designated to guide and unify advanced practice
nursing implementation efforts in the region (PAHO,
2015). One result was the creation of a six-part webinar
series in April 2016 titled Advanced Practice Nursing:
PAHO Activities and Strategy for Development in Latin
America (PAHO, 2016). The webinar was the collaborative endeavor of PAHO with McMaster University in
Canada and was presented simultaneously in English and
Spanish. The goal was to increase interest and awareness
of the APN role for nurses and key shareholders in Latin
America (PAHO, 2016). More than 300 individuals
registered for the series representing nursing in more than
20 countries in the PAHO region.
An outcome of the 2015 PAHO summit was a
meeting arranged by WHO-PAHO and the WHO
Collaborating Center at the University of Michigan
School of Nursing titled Developing Advanced Practice
Nursing Competencies in Latin America to Contribute
to Universal Health. This meeting was built on the
priorities set in 2015 to address APN competencies and
curriculum development (Schober, 2016).
The 2015 PAHO summit promoted collaboration
between nursing leaders and institutions in North America
NPs function in primary care health centers. As of July
2016 there are 80 NPs in clinical practice as family and
mental health/psychiatric NPs. NAs aretechnically classified
as NPs; however, even though the NA program started
many years before the NP program, it has yet to evolve
to the masters level.
Despite these achievements, NPs and NAs are not
registered or licensed as APNs and have no prescriptive
privileges. All NPs and NAs are registered as nurses or
midwives. They have no official authority in the expanded
role. Prescriptions must be countersigned by physicians.
NPs, NAs, the Nursing Council of Jamaica, and other
stakeholders on the island continue to work diligently to
move forward an agenda to enact policies supportive of
advanced nursing roles (D. Less, personal communication,
July 20, 2016).
Latin America
Historically, in Latin America most nurses are trained to
a baccalaureate level as licensed nurses or RNs. Nurses in
rural areas often provide primary care services to underserved populations, essentially practicing in an advanced
practice role. However, many lack formal skills training, a
defined role, and graduate level education to support this
degree of independent practice (Nigenda et al, 2010). In
2014 a PAHO strategy for universal access to health and
universal health coverage was approved (PAHO, 2014)
outlining key strategies for improving universal health,
including an increasing interest in moving forward with
an agenda for implementation of the APN roles.
In order to move this agenda forward, the Universal
Access to Health and Universal Health Coverage: Advanced
Practice Nursing Summit was hosted in 2015 by PAHO/
WHO and the Collaborating Center in Primary Health
Care & Health Human Resources at McMaster University in Hamilton, Canada. At this summit, participants
from across the region representing health ministries,
nursing associations, and nursing schools highlighted the
contributions of nursing with specific focus on APN implementation and roles in different countries and outlined
priorities for APN implementation (PAHO, 2015). The
overall goal for this summit was to address the APN role
in the promotion of PHC in the Americas. In addition to
defining the scope of nursing roles and advanced practice
nursing in Pan American countries, one specific objective

Chapter 5 Global Perspectives on Advanced Nursing Practice 67
Eastern Mediterranean Region:
The Eastern Mediterranean Regional Office (EMRO) of
the WHO serves 22 countries and territories in the Middle
East, North Africa, the Horn of Africa, and Central Asia.
In June 2001, the regional director of nursing for EMRO
convened the Fifth Meeting of the Regional Panel on Nursing
to discuss ANP and nurse prescribing (WHO-EMRO, 2001).
Countries represented at the 3-day workshop in Islamabad,
Pakistan, included Bahrain, Cyprus, Islamic Republic of
Iran, Iraq, Jordan, Lebanon, Oman, Pakistan, Saudi Arabia,
Sudan, Syrian Arab Republic, United Arab Emirates, and
the Republic of Yemen. Twenty-two representatives from
nursing, medicine, pharmacy, and ministries of health
gathered to begin to develop a regional policy framework
for ANP and mechanisms for nurse prescribing. The regional panel highlighted factors leading to development
of the roles, as well as identifying strategies for the region
(WHO-EMRO, 2001). Obstacles and factors identified as
supportive of development for ANP and nurse prescribing
are provided in Table 5.2.
Strategies were formulated for ANP development and
include the following:
Assessment of need and cost-effectiveness for APN
roles in the region
Development of APN curriculum and standards of
Definition of the role and identification of related
revision of nurse practice acts to cover ANP
Significantly, there was consensus that authority for nurse
prescribing within a range of essential drugs is an activity
that could be allocated at some level to the competent
general nurse and does not necessarily depend on the
development of ANP. On the other hand, authority to
prescribe was acknowledged as one of the many areas of
expertise associated with APN roles. In addition, it was
agreed that these nursing roles require advanced education,
regulatory changes, and expansion of traditional nursing.
Recommendations were madefor WHO-EMRO (2001)
to provide guidelines to assist countries in the region
that are in the process of developing and strengthening
ANP at all levels of health care. Additional assistance was
requested from WHO to initiate and coordinate pilot
and those in Latin America. In February 2016, the Faculty
of Nursing at Pontificia Universidad Javeriana in Colombia hosted a celebration of its 75-year anniversary titled
Posibilidades y Realidades de la Prctica Avanzada en
Enfermera en Colombia Frente a la Cobertura Universal
en Salud (Possibilities and Realities of Advanced Practice
Nursing in Colombia in the Face of Universal Health
Coverage) in Bogota, Colombia. A PAHO representative
participated and met with several nursing leaders and the
Ministry of Health to discuss aspects that could facilitate
advanced practice nursing in Colombia (Facultad de
Enfermera, 2016; Schober, 2016).
In Chile, since the time of the PAHO 2015 summit,
the University of the Andes has launched a masters degree
Nurse Practitioner in Adult Acute Care program. Although
the program is focused on the APN role in tertiary rather
than primary care, it is a historical step as the first program in Latin America that will produce graduates in
line with the ICN definition of an APN. The program is
a collaboration with Johns Hopkins Hospital and School
of Nursing in the United States. In addition to required
clinical hours in Chile, students will have the possibility
to participate in a 2-week internship at Johns Hopkins
Hospital shadowing a NP or nurse specialist in order to
understand the role and observe their practice (Magster
en Prctica Avanzada de Enfermera, 2016).
In an effort to initiate steps toward APN roles, representatives from the Federal Council of Nursing and the
Brazilian Nursing Association came to PAHO headquarters
in Washington, DC, in November 2015 to discuss and
plan the future of APN in Brazil. A decision was made to
join together and develop a document defining the scope
of the APN role in Brazil in PHC to be subsequently
presented to the MOH. An international seminar was
organized in June 2016 with all nursing organizations in
Brazil to increase visibility of the APN concept.
Along with recent success, challenges for APN implementation in the Latin American countries continue to
need attention. These issues include lack of recognition of
the significant role nursing has in strengthening health-care
systems, the development of postgraduate nursing education in countries where there may not have been existing
graduate nursing courses, and bringing changes to policy
that would allow nurses in APN roles to practice to their
full scope of practice (Schober, 2016).

68 Unit 1 The Evolution of Advanced Practice
associate degree (AD) nursing programs have been discontinued, the majority of the current Bahraini nursing
graduates come from these programs. Postbasic 1-year
education, called advanced practice programs, is available
in the country. Lacking a current option for a masters
program within Bahrain, nurses interested in obtaining
ANP education are sponsored by the Ministry of Health
to study in the United States or elsewhere (A. Matooq,
personal communication, March 14, 2008).
Bahrain faces certain challenges in developing an APN
role suitable for its health services:
Identifying services that could be provided by APNs
or NPs
Developing an educational plan that meets the needs
of the current workforce while properly planning for
potential APN roles
Constructing strategies to ensure faculty are adequately
qualified to deliver ANP education
Establishing standards and regulations supportive of
APN roles
In 2007 nurses were observed to be functioning in an
advanced capacity in triage centers but were not using
the terms NP or APN. Nurses were educated in the
United States for NP roles. However, they were employed
in hospital-based units and faced confusion by other
health-care professionals as they worked to establish a
new nursing role.
projects to evaluate the impact and cost-effectiveness of
related change when introducing new nursing roles and
nurse prescribing. As of July 2016 the progress in this
region has been uneven and limited because of ongoing
country conflicts;even so, there continues to beinterest and
progress toward the advancement of nursing. This initial
meeting in Pakistan stimulated interest and discussion
in the region that continues in Bahrain, Jordan, Oman,
Pakistan, and the United Arab Emirates (F. Aldarazi,
personal communication, June 21, 2016).
Because of the WHO-EMRO meeting in Pakistan in 2001,
Bahrain received additional consultative support coordinated by WHO-EMRO to assess the countrys readiness
for ANP (Schober, 2007b). Consultation services found
a stable organizational structure for health-care service
provision within PHC. Two pediatric APNs educated in
NP programs in the United States had started working
in pediatric specialties in a hospital. Additional NPs, also
educated in the United States, are faculty at the College
of Health Sciences (CHS).
The CHS has had an RN-bachelor of science in nursing
(BSN) degree for some years and established a 4-year BSN
program in 2003. The BSN is now considered entry-level
education for nursing practice in Bahrain. With proper
planning, this places the CHS in an ideal position to
develop an ANP masters degree program. Although the
Table 5.2
WHO-EMRO Consensus on Factors Influencing Advanced Practice Nursing Development
Obstacles Support
Lack of a regional definition and role ambiguity Increased population and community needs for health-care services
Absence of country-level educational or regulatory systems
to support such roles
Improving levels of nursing education
No feasibility studies for ANP needs Desire in the region to improve quality of care and access
No awareness of the role among the public and health
Research studies from outside the region supportive of advanced
nursing practice
Absence of nursing leadership at the policy level Commitment of WHO toward development and use of nursing roles
Adapted from World Health OrganizationEastern Mediterranean Region. (2001). Fifth meeting of the regional advisory panel on nursing and consultation
on advanced practice nursing and nurse prescribing: Implications for regulation, nursing education and practice in the Eastern Mediterranean. WHO-EM/
NUR/348/E/L. Cairo: Author.

Chapter 5 Global Perspectives on Advanced Nursing Practice 69
baccalaureate of science in nursing (BSc). The number of
postgraduate nursing majors has significantly increased
with 10 nursing majors at the masters level in different
specialty areas and one major at the doctoral (PhD) level
similar to the doctorate of nursing practice (DNP) in
the United States. In 2016 1,100 graduate students were
admitted in 10 specialized fields for a masters degree at
49 universities and for a doctoral degree at 14 universities.
The recent count shows that a total of 3,759 students
graduated with a masters degree (MSc) in nursing and
259 earned a PhD (M. Fooladi, A. Heydari, & F. Sharif,
personal communication, July 22, 2016).
Inspired in 2000 by a meeting of representative countries of
the WHO Eastern Mediterranean Region (EMR) focused
on advanced nursing capacity and nurse prescribing, nursing
leadership in Oman developed an aim to introduce the
APN/NP concept. The director of nursing services for
WHO in Cairo simultaneously had an agenda to promote
APN roles in the region including support for the interest
in Oman. The driving forces for ANP in Oman included a
shortfall in physicians,especially in the PHC settings, both
in numbers and specific expertise. In addition, emerging
health problems caused by lifestyle changes, increase in
life expectancy, and the global trend of moving care closer
and deeper into the community caught the attention of
the Ministry of Health.
Active interest in the development of the APN role
was initiated in 2004. Support for developing the role was
articulated by a WHO short-term consultant following
a review of the PHC delivery system in the country. A
situation analysis was then conducted in 2005 followed
by further consultations and workshops with health-care
professionals and key stakeholders in 2006 and 2007.
Reports provided to the WHO-EMRO and the Ministry
of Health in Oman demonstrated high utilization and
heavy patient load for physicians in larger health centers
with resultant restricted access to PHC services resulting
in potential poor outcomes and patient-provider dissatisfaction. In the many smaller and rural health centers
nurses were found to function in a context that includes
minor diagnosis and treatment. Thus, when there is no
physician in the health centers, nurses are providing care
beyond the scope of practice of their generalist nurse
education. The WHO consultants noted these conditions
A survey of primary care physicians (PCP) conducted
in Bahrain (Nasaif, 2012) to assess their knowledge of the
NP role found the PCPs had a poor understanding of the
NP role. The conclusion was that more education and
orientation to the NP role was needed to fully implement
this concept. As of July 2016 it is unclear the extent of
progress toward inclusion of the NP role even though
there has been interest in role development.
The first step toward advanced nursing in Iran occurred in
1976 with the initiation of a masters in nursing sciences
(MNS) in the areas of nursing education and nursing
administration with four subspecialties focused in psychiatric, pediatric, community health, and medicalsurgical
nursing. At thetime, 14 schools of nursing offered a masters
degree in nursing. In 1995, there were 10 doctoral degree
(PhD) programs in Iran that graduated 40 individuals to
be hired for clinical and academic positions in hospitals,
community centers, and universities.
The Farsi term Karshenasae-e-Arshad translates to
advanced specialist and is recognized by physicians in
major cities for nurses practicing in advanced roles and
direct patient care. In rural areas, Iranian nurses practice
autonomously, similar to the way APNs in most states
practice in the United States.
A practice permit is issued by the Iranian Ministry of
Health that allows advanced specialty nurses to open their
own private practice clinics as centers for nursing services.
Medical supervision by physicians is not required at these
centers because the state Ministry of Health monitors
health-care practice; however, physicians supervise the
scope of practice.
Societys needs for health-care services determine
curriculum content in academic nursing programs. In
2008, advances were made through an addition of practice emphasis in geriatric, rehabilitation, womens health,
neonatal health, military, and oncology nursing at the
graduate level. Short-term continuing nursing education
courses were made available by the Ministry of Health for
positions in school nursing, home health, intensive care,
wound care, ostomy care, HIV/AIDS, and geriatric care
at various levels.
As of July 2016, there were 181 schools of nursing in
Iran; 91 were government supported and 90 were privately
owned. Seven thousand students graduate yearly with a

70 Unit 1 The Evolution of Advanced Practice
In July 2016 BREXIT (British exit from the European
Union) had just been announced. For the purposes of the
chapter, development in the UK will be included with
the other countries of Europe and as listed under the
WHO designation. Note also that Israel is geographically
located in the Middle East; however, when reviewing
WHO-designated countries Israel is in the EURO region
and as such is included in this section.
The European countries are at different stages in considering or implementing APN roles. The initial development
in Europe was noted in 1991; the first NP educational
program was introduced in the Royal College of Nurses
in the UK (Sheer & Wong, 2008), thus catalyzing the
development in the UK. In Ireland, the first advanced
NP was accredited in 1996, and a career pathway toward
ANP was established following a Commission on Nursing
in the late 1990s (NCNM, 2005). The Netherlands has
a nearly 20-year history with the Dutch version of NP.
Other country initiatives are in the early stages, with
dramatic growth shown within the past five to ten years.
An example of a country in the early stages is Finland,
which officially launched their initiative in April 2016,
thus demonstrating the range of growth in Europe.
Increasingly, European universities are establishing
advanced nursing degree programs at the masters level.
Forexample, the University Medical Center, Groningen in
the Netherlands has had a program since 1997 (Donato,
2009) with specialties on managing chronic illness, critical and intensive care, acute care, illness prevention, and
psychiatric care. The University of Basel in Switzerland
has established a program in the German-speaking part
of Switzerland since 2000 with emphasis on managing
chronic illness (Sheer & Wong, 2008). In French-speaking
Switzerland the University of Lausanne and the University
of Applied Sciences and Nursing Science offer a joint master
degree. The program educates the nurse as a specialist
nursing clinical practitioner that is similar to a CNS role
(Schober, 2016).
The European Federation of Nurses (EFN)
and Advanced Practice Nursing in Europe
The EFN is the independent voice of more than three
million nurses in morethan 34 national nurses associations
(NNA), regulators, or unions at the European level. In
2011 EFN began to actively support advanced practice
nursing following Directive 2005/36/EC that highlighted
and a proposal was made by the WHO-EMRO in 2008
to develop the APN role at the primary, secondary, and
tertiary levels of care.
In 2010 and 2011 the Directorate General of Nursing
Affairs for the Ministry of Health continued to gather
information to support the development of advanced
nursing capacity by utilizing techniques that engaged key
stakeholders from service, education, and professional
regulation. The discussions were supplemented by a review
of relevant international literature. The results of these
analyses and discussions continued to demonstratesupport
for the introduction of ANP. In 2012, another follow-up
visit by two WHO consultants took place. The aim of this
visit was to review and analyze previous documents and
reports related to ANP and to meet with decision makers,
educators, and practice nurses. Two recommendations
resulted from the 2012 visit that emphasized actions
to develop the APN role and to educate nurses already
functioning in an extended capacity in PHC.
In 2016 a further WHO consultancy resulted in development of an on the job training (OJT) program for nurses
practicing in an extended capacity and in development
of the scope and standards of practice, service delivery
structure, practice environment, and legal framework for
the APN. In July 2016 the first advanced NP educated
in a NP program in the United States began practice in
Oman. Five more students in U.S. programs are scheduled
to return to the country in December and further nurses
are expected to enroll in U.S. NP programs. In addition,
structure for the OJT training for nurses already working
in health centers is planned to begin in 2017. There is
long-term interest by the MOH to eventually establish an
Omani NP program within the country (M. Al-Maqbali,
personal communication, April 7, 2016; M. Schober, site
visit, April 2016; S. Al Zadjali, personal communication,
July 12, 2016).
Europe: WHO-EURO
The WHO Regional Office in Copenhagen, Denmark,
serves the WHO European Region, which comprises
53 countries covering a vast geographical region from
the Atlantic to the Pacific oceans. The European Union
(EU) within this WHO region is composed of 27 different
member states. The APN roles are connected with the
historical and societal characteristics of each country.

Chapter 5 Global Perspectives on Advanced Nursing Practice 71
Developing wages that are consistent with role
Defining a plan to evaluate the effectiveness of APN
roles in the country
Estimating the number of APNs needed in the country
The significance of these recommendations was highlighted by the presence at the launching event of the
Ministry of Culture and Education, Ministry of Social
Affairs and Health, the National Supervisory Authority
for Welfare and Health, and the president of the Finnish Medical Association. This group of approximately
40 participants held a lively and productive discussion
in support of establishing APN roles in the country. The
next phase is a seminar when key stakeholders discussed
education and implementation of strategies to promote
the APN roles (A. Suutaria, personal communication,
May 5, 2016).
France is facing an increase in health-care needs similar
to many other Western countries. Current challenges to
the health-care system include an aging population, a
significant increase in chronic disease, scarcity of medical
services, and emerging absence of medical services in some
regions. National strategies are being developed to respond
to these challenges, including the introduction of APNs.
As early as 2003 the report Cooperation of the Health
Professions: The Transfer of Tasks and Competencies
(Berland, 2003) listed strategies aimed at addressing
the medical scarcity and envisioned the feasibility of the
transfer of tasks in the French context. Pilot projects then
followed. A series of reports ensued, allowing the Haute
Autorit de Sant (HAS), the French authority for health,
to formulate recommendations in 2008 (HAS, 2008).
Table 5.3 lists strategies for the adaptation of health-care
services to compensate for challenges associated with
implementing APN roles.
Two leading health organizations, HAS and Observatoire
National De La Demographie Des Professions De Sant
(ONDPS), appointed by the MOH in 2007, formed a
working group to explore future education for NPs, or
infirmiere cliniciennes, and to generaterecommendations.
They examined how roles of health-care professionals may
beredefined through thetransfer of tasks and competencies
from MD to RN to allied health professional (AHP) with a
the need to update and modernize education requirements
for nursing in Europe. The result was the strengthening
of the nurse education requirements standards and the
addition of a set of eight competencies. The EFN was very
much involved in the clarification of those competencies,
which were presented to the Parliament, council, commission, and stakeholders during a European Parliament
roundtable on nurse education in October 2012. Now that
Directive 2013/55/EU has been approved, EFN plans to
ensure that appropriate changes occur in every member
state for three categories of nursing: general care nurse
(RN), specialist nurse (SN), and advanced NP (M. Sipil,
personal communication, April 28, 2016).
Significant social and health-care reform in Finland is
providing momentum for the introduction of ANP in
the country. The anticipated benefits of the APN roles
are consistent with the main aims of the health-care
reform: to decrease inequity of social and health services,
to facilitate accessible health-care service provision for
country populations, and to improve the management
of health-care costs.
In Finland the concept of advanced practice nursing has
historically not been officially recognized even though there
are nurses in PHC and hospital settings who work in roles
that have advanced clinical components. Advanced roles
for RNs have been developed more systematically since
the early 2000s. The first role associated with ANP at this
time was that of the CNS. Limited authority to prescribe
medicines was introduced in the country in 2010. Even
so, the APN is in an early developmental phase in Finland.
A group of experts was selected by the Finnish Nurses
Association in 2013 to assess the circumstances for APNs in
Finland and to recommend actions for development. With
greatexcitement and anticipation thereport was presented in
April 2016. In addition to suggesting thetwo roles of CNS
and NP be considered, thereport described a clinical career
path for nurses in advanced roles.Thereport recommended:
Establishing coherent titles for the roles with defined
job descriptions
Making legislative changes relevant to advanced
nursing roles
Establishing appropriate education for nurses to obtain
relevant competencies

72 Unit 1 The Evolution of Advanced Practice
public information campaign on ANP, targeting nurses,
authorities, and the public.
New cooperation: A model of substitution between MDs, RNs,
and AHPS. The law Hpitaux-Patients-Sant-Territoires,
voted in 2009, authorizes in a local way and by name
more flexibility in the competencies of the medical and
nonmedical health professions while introducing the
concept of new cooperation (Article 51, 2009). See
Figure 5.1.
Although the question of transfer of activities of the
medical profession toward the paramedical professions
feeds the public debate, it is important to note that France
is undecided about several structuring models. New
cooperation, intermediary professions, and APNs arethree
concepts that coexist currently in discussions and reports
without succeeding to be stable in France semantics and
thus remain problematic. This lack of conceptual clarity
generates a lot of confusion. Although the validation of a
view of improving care and adapting interventions to actual
health-care demands (HAS, 2007). Preceding theformation
of this working group, fivetentative projects to implement
new task allocation between MDs, RNs, and AHPs in
dissimilar areas of the country had been completed. Ten
additional projects concerning role redefinition followed
(C. Debout, personal communication, June 17, 2016).
Historically, although French nurses did acquire increased
autonomy in 1978, they are still not considered a point of
entry into the health-care system. Private practice nurses
in contract with the French health insurance system
(infirmires liberales) depend on a medical order to deliver
professional nursing care. Recognizing that the current
arrangement of the health-care workforce will be inadequate to respond to future health-care needs, the health
authorities considered alternatives that included implementation of APN roles. Capitalizing on this situation,
the French nurses association (ANFIIDE) conducted a
Table 5.3
Steps in Development of Advanced Practice Nursing in France
Year Steps
1990s Introduction of CNSs in the French context
2003 Berland Report: Consideration of task transfer between medical and nonmedical health professionals
2004 First trials aiming to transfer medical activities to nonmedical health professionals (five pilot projects)
2006 Second trials (10 new pilot projects and three renewed projects)
2007 Reports from a group of experts as to the modification of the fields of health professional competencies
(focus: economic, legal, formation) of the Haute Autorit de Sant (HAS)
2007 (May/December) Public consultation of the HAS, aiming to determine the functions between health professionals
(334 testimonies)
2008 Recommendations of the HAS in the matter of the new cooperation between health professionals
Mission: Reflection around the sharing of tasks and the competencies between health professionals
(report not circulated)
2009 Adoption of the law for the patient health territories hospitals, introducing the new cooperation between
health professionals (article 51 and application texts), launching of the first masters of science in
clinical nursing intended for the education of APNs (EHESP/Universit de la Mditerrane)
2011 Report related to midlevel professionals
2016 A new public health law officially introduces advanced practice for nurses and APNs
Implementation of this law is still to come
Source: C. Debout, personal communication, June 17, 2016.

Chapter 5 Global Perspectives on Advanced Nursing Practice 73
Toward intermediary professions. A report relating to the
new intermediary-level health professions, published in
2011, defines the characteristics of the APN in France
(Henard et al, 2011).
A master of science in clinical nursing. The first master in
science for clinical nursing was launched in 2009 jointly by
the department of nursing science and AHP science section
of lEcole de Hautes Etudes en Sant Publique (EHESP) and
Aix-Marseille Universit (faculty of medicine). In 2014,
the department of nursing science of EHESP ended its
activities because of budget restrictions; as of June 2016
this program was only implemented by Aix-Marseille
Universit. This program, a forerunner in France in the
domain of the education of APNs, rests on a vision of
advanced practice nursing in the international context but
specific to France. When the Ministry of Higher Education
approved this program, the Ministry of Health strongly
supported this initiative. Currently three specialties are
proposed: oncology, gerontology, and coordinator of
complex health-care conditions. A second program was
launched at the University of Versailles-Saint Quentin en
Yvelines (school of medicine) offering three specialties:
psychiatry and mental health, palliative care and pain
control, and chronic diseases.
Many French universities had projects to develop similar
programs in different parts of the country; however, as of
2017, the Ministry of Higher Education was opposed to
giving approval to new programs in this field. The French
protocol of cooperation imposes on the delegated nurse
to combine required competencies to implement the
designated activities, no qualifying education is required
currently from a regulatory perspective.
The processes of revision of the diplomas of specialties certified
by the Ministry of Health. The Ministry of Health engaged in
a vast project aimed at revising the competencies and the
education programs for three clinical specialty diplomas
that it currently certifies: pediatric nurse, operating room
nurse, and nurse anesthesiologist. This project is in line
with the vast reformation of nursing education that seeks
reconciliation with the university-based model coming
from the Bologne agreements.
Initially, this project will develop a competence framework
for every function from a descriptive and retrospective
analysis of the activities of the professionals in these
positions. Theintent is to adopt a long-term approach that
anticipates the evolution of the functions and activities of
the professions wherein they address the health needs of
the public. Leaders representing the professional specialty
organizations requested that the specialties be viewed
as advanced practice and that therecommendations developed by this network guidetherevision of both education
and practice (regulations, design of masters education,
definition of autonomy). The negotiations related to
the various points of view are in process, and decisions
are still to come (C. Debout, personal communication,
June 17, 2016).
Second step
Validation process
at regional level
Who will do what
and how under
which supervision?
First step
At micro level:
(ward or home care
Writing the agreement
health authority
health authority
Ms T, MD
Mr V
Figure 5.1 Visualizing the concept
of new cooperation in the French law,

74 Unit 1 The Evolution of Advanced Practice
practice(SVR Gesundheit, 2007). Additional support from
key stakeholders representing nursing and highereducation
institutions paved the way for ANP developments across
the country (Jeschke, 2010; Ullmann & Lehwaldt, 2013;
Ullmann et al, 2011). According to Ullmann and Lehwaldt
(2013) there arefew masters level programs available across
Germany thateducate nurses for roles in advanced practice.
Nurses with advanced clinical competencies in Germany
commonly obtain these skills in other countries such as
Ireland or those of the UK that have a longer history of
ANP. Examples of programs based in Germany are at the
University of Applied Sciences, Frankfurt am Main with an
ANP masters program established in 2010 and the Clinical
Masters Programme at Hochschule fr Angewandete
Wissenschaften in Hamburg established in 2013.
There is no legislation in place to award and protect the
APN. The title Pflegeexpertin APN, which translated into
English means nursing expert APN, has been suggested
for Germany (Ullmann et al, 2011). A legislativeframework
that formalizes a system for title protection, licensure, registration, and credentialing is needed. Without legislation
to protect the title, as of July 2016, there is no consensus
as to necessary roles and responsibilities that go with this
title. Therefore, ANP in Germany seems to be developing
from the bottom up as suggested by Teigeler (2015) who
reported on 17 APNs who practice at a university hospital
in south Germany. Hospital administrators are supportive
of these APNs who work in direct patient care.
Deutsches Netzwerk APN & ANP g.e.V. was formed
to offer nurses, institutions, and others with an interest
in developing advanced nursing roles ongoing support.
The activities facilitated by the Netzwerk include periodic
international congresses, expert workshops, and an ANP/
APN publication. With a goal to facilitate discussion and
political debate, it is hoped that the necessary structures
for ANP in Germany will continue to evolve and progress
(D. Lehwaldt & P. Ullmann, personal communication,
April 27, 2016).
A Commission on Nursing in Ireland in 1998 acknowledged the need to provide a career pathway for nurses
and midwives who wanted to remain in clinical practice
and progress from entry level to clinical specialization
linked to advanced practice. Subsequently, the National
Council for the Professional Development of Nursing and
government elected in 2012, especially the Ministry of
Health, was not supportive of these projects. As a consequence, many graduates from the two earlier programs
had difficulties using the competencies developed in the
masters program because of a lack of implementation at
the national and local level.
Unresolved issues. When examining the position of France,
key words such as protected title, qualifying education, and
specific regulations often associated with the APN roles
are not yet observable. The methodology in the framework for the protocols of cooperation, while showing a
response to local needs, makes development of national
competencies difficult. No national directive existed in
relation to this until January 2016. A national position
to stabilize the APN concept and a defined regulatory
process, including both education and practice, was
urgently needed.
In January 2016, a new public health law was voted
on by the French Parliament to modernize the healthcare system. In this law, one article introduces advanced
practice for nurses and AHPs. The title of advanced
practitioner will be protected. To practice as an APN
an additional qualification will be required; however,
the law does not specify whether this qualification will
be at a masters level. APN practice will be regulated.
Regarding their scope of practice, physicians in the
hospital or in the community will strictly supervise
them. The APN will have prescriptive authority but
more as a supplementary prescriber rather than prescribing independently. As of June 2016 this article
was still waiting implementation (C. Debout, personal
communication, June 17, 2016).
As with other countries in Europe, Germany is emerging
as a country in the early stages of ANP development.
Evidence of thisenthusiasm and progress was demonstrated
in Munich in 2015 at the Third ANP/APN Congress
for German-speaking countries. Delegates from Austria,
Germany, and Switzerland represented German-speaking
countries with an additional presencefrom Canada, Ireland,
the Netherlands, and the United States.
The stimulus for ANP development in Germany is
attributed to the expert group Sachverstndigenrat zur
Begutachtung der Entwicklung im Gesundheitssystem
that recommended that nurses should widen their scope of

Chapter 5 Global Perspectives on Advanced Nursing Practice 75
provide a forum to debate issues and concerns, promote
professional development, and link to other international
organizations (
As of July 2016 there was no nurse practice act (NPA) in
Israel. All nurses practice under a clause of the Physician
Practice Act passed during the establishment of the state in
1947 and revised in 1976. Therefore, the scope of nursing
practice is not specifically defined by law but by executive order of the Ministry of Health and by institutional
policies. The Division of Nursing within the Ministry of
Health registers nurses who have successfully completed a
course of study and have passed a qualifying examination.
There are registries for licensed practical nurses, registered,
postbasic nursing certification, and APNs (Ministry of
Health, 2016b).
The introduction of APN occurred in 2009 by an
executive order identifying the role of nurse specialist in
palliative care (Ministry of Health, 2009). Requirements
for the role are a baccalaureate and masters degree (where
at least one degree is in nursing), postbasic certification in
oncology or geriatrics, an advanced palliative care course,
and successful completion of a theoretical and clinical
examination. Thirty-five nurses with experiencein palliative
care and postbasic certification were grandfathered in as
specialists (Ministry of Health, 2016a).
The role of geriatric nurse specialist was introduced
in 2011. In 2013, the Ministry of Health published an
executive order standardizing the specialist role within
the health-care system (Ministry of Health, 2013) that
not only defines the requirements for the role but also
provides the scope of practice. Since 2013, additional
specialist roles have been introduced and other specialties
are in the planning phases (Ministry of Health, 2016a).
As of July 2017, one geriatric specialist course is available
that has graduated 19 nurses who are registered as geriatric
nurse specialists.
The changes in Israel are positive and dynamic; however, qualified nurse specialists continue to work as staff
nurses and not to the full extent of their scope of practice.
In addition, education is usually not provided within
an academic structure. In spite of this and a shortage
of nurses in the country, development of the advanced
practice role is progressing (F. DeKeyser Ganz, personal
communication, May 4, 2016).
Midwifery (NCNM, 2001) provided a framework for the
establishment of ANP and advanced midwife practitioner
(AMP) roles and posts. This decision was a response to
the national and international development of advanced
practice in nursing and midwifery. Since these early efforts,
research in Ireland has convincingly demonstrated that
ANPs and AMPs provide quality care, improve health-care
outcomes, and offer care that is acceptable to patients and
cost neutral (Begley et al, 2010).
In 2011, once the NCNM was dissolved, the Nurses
Act of 2011 provided for a distinct division for registered
advanced nurse practitioners (RANPs). RANPs are now
registered with the Nursing and Midwifery Board of
Ireland (NMBI [Bord Altranais agus Cnaimhseachais na
hEireann]). An applicants portfolio must link the job
description of the post or location site to the qualifications
of the person seeking registration as an ANP. There must
be clear evidence that the person who is applying for
registration either as an ANP or AMP has the expertise,
advanced knowledge and clinical skills, advanced clinical
decision-making capabilities, leadership skills, research
skills, and clinical wisdom to fulfill the advanced practice
role. A masters degree(or higher) is required with evidence
that reflects experience and preparation in a specialist area
of practice ( As of May 31, 2016,
NMBI reported there were 183 RANPs and 7 RAMWs
in the country.
Updated Standards and Requirements for Advanced Practice
(Nursing) and Standards and Requirements Advanced Practice
(Midwifery), based on an interim report (WGAP, 2014), are
due for publication later in 2017. In advance of these
modifications, NMBI has made several changes: A new
interim revalidation process has been established, all
advanced practice forms have been reviewed and updated,
updated guidelines for advanced practice portfolios have
been developed, and updated information was developed
in relation to advance practice posts. It is anticipated that
the new guidelines will provide a more flexible structure
for matching the RANP/RAMW candidate/applicant
with the post or location site for practice (K. Brennan,
personal communication, May 15, 2016).
The Irish Association of Advanced Nurse and Midwife
Practitioners (IAANMP) wasestablished in 2004 to provide
a forum to support persons interested in promotion and
development of ANP and AMP in Ireland. The association aims to support nurses practicing at advanced levels,

76 Unit 1 The Evolution of Advanced Practice
used in Sweden is advanced clinical nurse specialist (ACNS)
(Lindblad et al, 2010).
In Skaraborg, the PHC authorities worked with the
University of Skovde to develop a model and educational
program that met the requirements of the National Board
of Health and Welfare. The primary consideration was
PHC for the community and care of the elderly with the
ACNS as the vehicle to address these needs. The initial
batch of students enrolled in 2003 faced challenges
to introduce a new nursing role that fits the Swedish
health-care system and is acceptable to all stakeholders.
In the process, a definition for the ANP was negotiated
(Schober & Affara, 2006, p. 6):
An Advanced Nurse Practitioner in Primary Health Care
is a registered nurse with special education as a district
nurse with the right to prescribe certain drugs, and with a
post graduate education that enables [the advanced nurse
practitioner] an increased and deepened competence to be
independently responsible for medical decisions, prescribing
of drugs and treatment of health problems within a certain
area of health care.
Prescriptive authority for nurses in Sweden has been in
place since 1994, before the consideration and development of an ANP. Literature reveals that although there is
interest in the idea of advanced nursing, demarcation of
the role relative to physicians and appropriate integration
of advanced practice nursing into the health-care workforce remains unclear (Jangland et al, 2014; Lindblad
et al, 2010).
Advanced nursing practice was introduced in 2000 in
Switzerland with the first master of science in nursing
program at the Institute of Nursing Science (INS) at the
University of Basel, Switzerland. A shift to masters level
prepared nurses in clinical specialist roles and development
of masters degrees at other academic institutions from
2004 further encouraged the introduction of APN roles
in a variety of clinical settings.
A Swiss definition for ANP, based on theICN definition,
was announced in 2012. The definition was the result of a
collaborative effort by the Swiss Nursing Association, the
Swiss Association for Nursing Science, SwissANP, and the
University Institute for Nursing Education and Research
in Lausanne. Research on ANP in Switzerland has been
conducted (Kambli et al, 2015; Mller-Staub et al, 2015;
In the Netherlands the Dutch title that is used for
the advanced nursing role is nurse specialist (NS). The
concept of NP caught the attention of decision makers
in the country nearly 20 years ago, but the words nurse
practitioner could not be translated into the Dutch
language. Since 1997, when the idea was introduced,
there have been great strides in development in the
country. Progress during the period 1997 to 2016 is
because of multiple factors, but particularly support
from the Dutch government.
In 2004 grants and supportive salaries were made
available by the government for those nurses wanting
to undertake advanced study. This plan was organized
in collaboration with health-care institutions that took
on the role of employer during the time the nurse was
a NS student. In 2009 legislation was developed to
guarantee the quality of education and work for the NS.
The professional regulations provided title protection
and stipulated standards for education, registration, and
practice. In 2011 additional legislation expanded the
authority for scope of practice for the NS with scope
of practice and authority closely linked to the practice
specialty chosen by the NS.
As of February 2016, approximately 2,750 NSs
have been educated and registered in the country. Ten
universities of applied sciences in the Netherlands offer
a NS education program. In close collaboration, the
universities have developed a competency-based program intended to be consistent across all universities
in the Netherlands.
The shortage of physicians that prompted the
introduction of NS roles in the Netherlands has been
resolved, but the numbers of NSs continue to increase.
At one point it was thought that the introduction of PAs
would threaten NS development, but this has not been
the case. The NS in the Netherlands has been accepted
as a professional that provides high-quality care and
friendly advice (J. Peters, personal communication,
February 17, 2016).
Sweden introduced the concept of advanced nursing roles
as a strategy to improve access to PHC, especially care of
the elderly in the community. Educational programs have
been established with these clinical foci in mind. The title

Chapter 5 Global Perspectives on Advanced Nursing Practice 77
number of universities providing such programs has
In November 2001, a decade after the first RCN NP
course had begun, theinaugural meeting of the UK National
Organization of Nurse Practitioner Faculties (NONPF)
took place. Membership slowly increased and led to the
establishment of a formal link with the national RCN Nurse
Practitioner Association. In 2005, UK NONPF changed
its name to the Association of Advanced Nursing Practice
Educators (AANPE) and was formally re-launched as a
new independent association. Since that time, AANPE
participated in professional, regional, and country-specific
advanced practice discussions, consultations, and policy
development across the UK. In 2015, the association
renamed itself as the Association of Advanced Practice
Educators (AAPE UK) to reflect the growth and maturity
of advanced practice in a broad multi-professional context
in the UK.
Despite all the energy, dynamics, and growth in the
UK, regulation of NP practice has not yet been established
for NPs in the UK. The term advanced NP has been
adopted by many NPs and is now the preferred term.
A proposal to formalize and legally protect the NP role
at the national level was scrutinized by the Department
of Health and the Council for Healthcare Regulatory
Excellence(CHRE, 2010). It was concluded that there was
insufficient grounds for additional regulation for NPs who
were already registered as nurses. Despite this, debate on
the need for regulation of ANP continues (K. Maclaine,
personal communication, February 15, 2016).
Southeast Asia: WHO-SEARO
The WHO South East Asia Region (SEAR) has 11 member
states: Bangladesh, Bhutan, Democratic Peoples Republic
of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri
Lanka, Thailand, and Timor-Leste. This section provides
one example of APN development in the region.
The Thailand Nursing and Midwifery Council (TNMC)
adopted the ANP concept in 1998, and in 2003 the first
group of 49 APNs was certified and awarded thetitle APN.
TheTNMC defines the APN as a RN with a masters degree
who is qualified according to criteria set by the TNMC.
The TNMC creates rules specifying which professional
Serena et al, 2015) and a framework for role evaluation
has been developed (Bryant-Lukosios et al, 2016). In spite
of this progress, APN roles are not yet legally protected or
formally credentialed as of July 2017. Legislation to regulate
health-care professions at the bachelors and masters level
for the entire country is in progress. There is interest to
develop a legal framework for ANP (K. Fierz, personal
communication, May 18, 2016).
The INS at the University of Basel has had a leading
role in promoting the view of ANP education and role
development in the German-speaking world, not only for
Switzerland but also for other German-speaking countries.
From French-speaking Switzerland thereisearly development
in Lausanne for a specialist nursing clinical practitioner.
As of July 2016, the University of Lausanne (http://www and the University of Applied Sciences
Western Switzerland ( offer a joint
master of science in nursing sciences for this APN role.
United Kingdom (England, Northern Ireland,
Scotland, and Wales)
The four countries of the UK (England, Northern Ireland,
Scotland, and Wales) are developing ANP in different
ways. The emergence of the NP movement in the UK
has been described as a response to the changing demands
within health-care systems and acknowledgment that the
traditional medical model alone is not sufficient to provide
comprehensive health care for community populations
(White, 2001). A reduction in doctors hours and an
overall shortage of general practitioners in some areas
accelerated the move toward NPs in acute and primary
care settings. In addition, government-initiated pilot
programs to address the needs of special groups, such as
refugees, the homeless, the mentally ill, traveling families,
and the elderly, increased the use of NPs and provision of
services in a range of settings.
The NP degree program, originally developed by the
Royal College of Nursing (RCN) in 1990, formed the
basis for RCN accreditation of NP programs. In 2002
the first graduates from the RCN program celebrated
their 10th anniversary. The initial 15 graduates paved the
way for NPs now practicing throughout the UK (RCN,
2008). Different pathways of NP preparation still exist,
ranging from a generic approach to a growing tendency
to establish academic preparation at the masters degree
level. As demand for NPs and APNs has increased, the

78 Unit 1 The Evolution of Advanced Practice
the complexities of role development and implementation
when proceeding with the APN concept.
As of July 2016, there were two types of NP programs.
The masters degree requires 42 credits to achieve APN
accreditation and usually requires approximately 2 years
of education. The curriculum is concentrated on an
advanced graduate certificate designed for APNs. The
second type of NP program involves specializing as a NP
(primary medical care), which is a short course with 18
credits and a 4-month period of study (P. Buaklee, personal
communication, June 20, 2016). To facilitate development, the Thai Bureau of Nursing recommended that the
PEPPA framework developed by Canadian researchers
Bryant-Lukosius and DiCenso (2004) be used as a guide
for the introduction and evaluation of APN roles for
further development in the country (Sathira-Angkura &
Khwansatapornkoon, 2014).
Western Pacific: WHO-WPRO
The WHO Regional Officefor the Western Pacific (WPR) is
located in Manila, the Philippines, and represents 37 countries
and areas in the Asia Pacific. The region stretches from the
Peoples Republic of China in the north and west to New
Zealand in the south to French Polynesia in the east. As
one of the most diverse of the WHO regions, the WPR
constitutes some of the worlds least developed countries as
well as the most rapidly emerging economies. It includes
highly developed countries such as Australia, Japan, New
Zealand, the Republic of Korea, and Singapore, as well
as fast growing economies such as the Peoples Republic
of China and Vietnam.
Australia first considered the development of NP roles in
1990 (Offredy, 1999). Pilot projects were conducted first
in New South Wales (NSW) and then in most other states
and territories of Australia. The results from the initial
projects found that NPs are feasible, safe, and effective in
their ability to provide high-quality health-care services
in a range of settings (Gardner & Gardner, 2005; NSW
Health Department, 1998).
In Australia, the NP title is protected and only nurses
who have been authorized by the National Nursing and
Midwifery Registration Board of the Australian Health
Practitioner Regulation Agency may use the NP title.
nursing organization certifications can be accepted for
APNs and sets requirements for education, training, and
experience. Terms accepted as advanced practice nursing
include certified nurse-midwife (CNM), certified registered
nurse anesthetist (CRNA), CNS, and NP. APNs work in
one of ten specialist areas: medical/surgical, pediatrics,
maternal/child, community care, elderly care, psychiatric,
NP, midwifery, infection control, or anesthesia (P. Buaklee,
personal communication, June 20, 2016).
In responseto an urgent need for community health-care
services, the country identified short- and long-term goals
to offer 4-month education programs for general NPs to
work in the community as primary care providers. Even
though one of the first postbasic NP programs was established in the 1970s, it was health-care reform and the drive
for a universal health-care coverage system, implemented
in the country in 2002, that accelerated the development
of NP educational programs.To identify the strategic approach of NP education Hanucharurnkul and colleagues
(2007) conducted a study that explored characteristics
and work settings of 1,928 NPs and provided a picture
of those certified by the TNMC. Strategies derived from
this study are as follows:
Extend within 5 years the entry-level education to a
masters level by acknowledging the 4-month programs
that were originally initiated to respond to PHC needs
of the country.
Establish NP positions in the health-care system such
that when APNs are masters graduates and certified,
they are eligible for the title of APN/MN and have an
associated increase in salary.
Results of a study on role development in Thailand conducted by Wongkpratoom and colleagues (2010) revealed
that even though a certified APN role was functioning to
some degree in the country, most APNs only occasionally
served in an advanced practice capacity because of various
organization, human, and resourceissues. Major facilitators
include supportive organizational policies, quality nurse
administrators, well-functioning multidisciplinary teams,
and financial resources. Conversely, study findings revealed
that barriers included lack of a clearly delineated organizational structure and unclear organizational policies, poor
administrative support for the APN (work assignments
were not reflective of advanced nursing practice), and
uncooperative team members. Study findings confirm

Chapter 5 Global Perspectives on Advanced Nursing Practice 79
As of September 2015, there were 1,287 endorsed NPs in
Australia comprising a small but increasing component
of the 261,582 nurses in the workforce (Schober, 2016).
A study conducted in 2010 (Gardner et al, 2010) found
that two-thirds of NPs in Australia reported their role
was extremely limited because of a difference between
state and federal governmental laws. These results were
similar to those from an earlier survey undertaken in
2009 (Gardner et al, 2009). Until late 2010, NPs were
able to write prescriptions and refer patients to other
health-care professionals at a state level; however, at a
federal level, NPs did not have access to the pharmaceutical
benefits scheme (PBS) or the Medicare benefits schedule
(MBS). Therefore, patients paid a premium when their
prescriptions were filled at a pharmacy or when they had
pathology tests undertaken. This situation placed patients
at a disadvantage because they did not have equal access to
government subsidies for health care. In November 2010,
national legislation was enacted to enable NPs to obtain
provider numbers, potentially reducing costs to patients.
As of July 2017 this legislation is primarily limited to NPs
in private practice.
In Australia, NPs aresteadily being introduced throughout the country while continuing to face country-specific
challenges. The Australian College of Nurse Practitioners
( has been established to provide
a representative voicefor NP role development in Australia
(A. Green, personal communication, July 22, 2016).
Brunei Darussalam
The Nursing Services Department, Ministry of Health,
Brunei Darussalam is proceeding forward in exploring
ANP for the nurses in Brunei and for the health-care
services in the country. To motivate the nurses and provide a strategic action plan to the MOH, a workshop and
symposium were held in July 2011 to gain an understanding of ANP as an option for the future of the public. A
resolution and recommendations were presented to the
MOH for development of a nursing career pathway for
clinical practice along with organization of a task force to
promulgate criteria, standards, and regulations for ANP.
Debate has been focused around alignment of NP roles
with nurse-midwives under the ANP umbrella, as well
as clarification of where the specialist nurse fits in the
future scheme for Brunei Darussalam (M. Schober, site
visit, July 2, 2011).
A study by Gardner, Dunn et al (2006) recommended
the masters degree as the required educational preparation for the role from two perspectives. Study findings
suggested that a masters education is needed to meet
the demands of the role and to also provide necessary
credibility with the community and other health-care
disciplines regarding the professional standing of these
clinicians. The national registration board adopted
this recommendation and mandates that a masters
specifically for the NP is the minimal level of education
required to practice.
The Nursing and Midwifery Board of Australia has two
pathways for nurses to fulfill theireducational requirements
at the masters level for endorsement as an NP:
1. Successfully complete a board-approved NP program
of study at the masters level
2. Complete a program of study at the masters level that
is clinically relevant to the nurses context of advanced
practice nursing for which they are seeking endorsement as a NP and complete supplementary education
that demonstrates equivalence and meets the national
competency standards for a NP
Having the two educational pathways provides flexibility
for nurses to choose an educational program that best
meets their individual learning needs.
The Mutual Recognition Act of 1992 and the Trans
Tasman Mutual Recognition Act of 1999 recognize nurses
educated in all states of Australia and those educated in
New Zealand regardless of differences within programs.
In 2004, the Australian Nursing and Midwifery Council
(ANMC) in conjunction with the Nursing Council of New
Zealand commissioned a project to develop competency
standards for the NP to further ensure delivery of safe
and competent care (Gardner, Dunn et al, 2006). These
competency standards were used to assess NPs educated
overseas and by the Australian Nursing and Midwifery
Accreditation Council (ANMAC, 2010) for accrediting
universities and NP masters programs.
In 2014, the NP competency standards were reviewed
and the following four standards were implemented:
Assesses and uses diagnostic capabilities.
Plans care and engages others.
Prescribes and implements therapeutic interventions.
Evaluates outcomes and improves practice.

80 Unit 1 The Evolution of Advanced Practice
the Pacific Islands include the following (WHO-Western
Pacific Region [WPRO], 2001):
Nurses are already present in the workforce of most
countries and usually comprise the largest category of
health professionals.
Nurses are currently living and working in underserved
Nurses are providing a wide range of preventive and
curative services.
Nurses are considered to be an adaptable, multitalented
resource of the workforce.
Strategies recommended by WHO-WPR for developing
and sustaining a midlevel practitioner workforce include
the following (WHO-WPR, 2001):
Legal protection
Standard treatment guidelines
Ongoing clinical supervision
Continuing education
Career structure or career ladder
Fiji is made up of more than 300 islands, with more than
60% of the population living in rural or remote settings.
Through an arrangement of health centers and nursing
stations, authorities have attempted to address health-care
challenges by providing preventive and PHC services
supported by subdivisional and referral hospitals.
Staffing of facilities has been a major problem,especially
in rural and remote areas. In response to this difficulty, an
NP program was developed in 1988 and taught by staff
within the then Fiji School of Nursing (FSN). In 2010 the
school merged with the Fiji School of Medicine to form
the College of Medicine, Nursing and Health Sciences
within the Fiji National University. The NP program is
now delivered as a two-semester, 13-month postgraduate
diploma in nursing practice as a NP.
The program has a regional orientation and students are
accepted from other islands in the WPR. In 2011, the Fiji
government passed Nursing Decree 2011 that provided
the legal framework for the establishment of the new Fiji
Nursing Council to take over responsibilities from the
Nurses, Midwives and Nurse Practitioner Board. Annual
registration is now required by all NPs in Fiji (as well as
student nurses, midwives, RNs, and specialist nurses) and
The MOH of Brunei, with the intent to strengthen the
implementation of theregistration of nurses into the Nursing
Board for Brunei (NBB) and heighten the monitoring of
nursing practices in the country, announced the Nurses
Registration Act (Amendment) 2014. The amended Nurses
Registration Regulations 2014 and Nurses Registration
(Committee) Regulations 2014 were enforced in March
2014. The MOH highlighted that the new amendments in
the act will protect the safety of nursing services and hoped
that with the new nursing service scheme local nurses will
reach the level of NP. As of July 2017 it remains unclear
as to whether this role has become part of the health-care
workforce in the country.
Hong Kong, China
Hong Kong has been pursuing the concept of the APN
for many years while facing complicated governmental,
clinical, and academic challenges. The Hospital Authority
of Hong Kong, eager to motivate nurses to remain in
clinical practice, introduced the NS position in 1994. As
of 2014 a clear clinical pathway for nurses developing as
a specialty with the APN title was available. Once a nurse
has achieved APN status within the Hospital Authority
System the next progression along the career path is as a
nurse consultant.
Advanced practice nursing education is at the
postgraduate level with APNs running more than 100
independent nurse clinics in Hong Kong. The Hospital
Authority Annual Report 20112013 indicated that there
were 2,700 APNs and 70 nurse consultants. Nurses
in Hong Kong endeavor to establish a statutory body
to regulate ANP, with the Provisional Hong Kong
Academy of Nursing set up in 2011 for this purpose
(Wong, 2014).
Islands of the WPR (Fiji, Guam, Northern Mariana
Islands, and Samoa)
NPs and other midlevel practitioners have provided
health-care services for the populations of the Pacific
Island countries for more than 20 years. The rural and
remote nature of this region and a shortage of physicians
encouraged governments to explore the most appropriate
models to provide comprehensive health-care services.
Demographics help determine the best approach for the
Pacific Islands in initiating education and practice guidelines for NPs. Reasons for educating nurses for NP roles in

Chapter 5 Global Perspectives on Advanced Nursing Practice 81
of patients and for the referral of cases and the procedure
for an alternative collaborating physician. Periodic review
of the agreement must be done during the first year after
signing the agreement and then every 6 months thereafter.
If the collaborative agreement is terminated, either by the
physician or the APRN, the APRN must inform the board
in writing within 3 working days, and the license issued
to the APRN will immediately terminate.
APRNs with a current license may apply for prescribing
authority and must submit documentation of successful
completion of advanced pharmacology coursework. In
addition, the APRN must provide evidence of a minimum
of 1,000 hours of practice as an APRN before application
for prescriptive authority. The 1,000 hours must include
clinical hours completed and verified by the collaborative
physician within the past 24 months. When approved, a
new APRN license card is issued indicating the qualification for prescriptive authority. Prescribing stipulations
include legend drugs, diagnostic studies, and therapeutic
devices as outlined in the protocols section. Controlled
substances (Schedule IIV), defined by federal controlled
substances lists, will be prescribed and administered or
ordered as established in the protocols, provided that the
APRN has an assigned DEA registration number.
The Guam NPA revisions are modeled after the National
Council of the State Boards of Nursing (NCSBN) NPA in
the United States. The NPA committeeis working on revising
the Guam NPA under the Guam Nurses Association (GNA)
and the Guam Association of Advanced Practice Registered
Nurses (GAAPRN). It is moving forward and hopes to be
the next jurisdiction with full practice authority and APRN
regulation with the majorelements of the U.S. Consensus
Model. There are several professional organizations that
support APNs in Guam including the GAAPN, GNA, the
Asian American/Pacific Islander Nurses Association, and
the American Pacific Nursing Leaders Council.
Guam has been fortunate to have a strong relationship
with three representatives of the American Association of
Nurse Practitioners (AANP). All are dedicated to increasing
access to high-quality health care for Guams population.
These three have made significant contributions as NPs
in Guam and provide constructive energy to facilitate
APRN practice in Guam and the PacificTerritory. Guams
nurses are very dedicated to their rural populations health
care. They are cohesive, belong to the GNA, and meet in
professional conferences twice yearly.
evidence of annual engagement in relevant continuing
professional development (CPD) activities is now expected.
NPs in Fiji have an established scope of practice and
work under published protocols, allowing them prescriptive privileges. The Ministry of Health employs most NPs
with postings for positions listed by the Public Service
Commission. These nurses have been widely accepted
by communities and other health-care providers. There
is strong support from the directors of health services to
continue the education program. Access to continuing
education, an identified career pathway, and opportunities
for locum relief are among the challenges facing NPs in
Fiji (D. Lindsay, personal communication, June 30, 2016).
Guam is a 210-square-mile tropical island located
3,950 miles from Hawaii. Although Guam is a U.S.
territory, it is in the WHO-WPR. It is designated as a
rural area based on its population density.
Guam has one public hospital, the Guam Memorial
Hospital (GMA); the Guam Naval Hospital (GNH); and
the new private hospital, Guam Regional Medical Center
(GRMC). There is a shortage of health-care professionals
on the island, and Guam struggles to provide health care
to the uninsured and those who receive public assistance
for an estimated population of about 168,000.
The Guam Board of Nurse Examiners (GBNE) is a
regulatory body of nurses appointed by the governor. A
NP serves as the chair of the GBNE. The administrative
rules of the Board of Nursing NPA were most recently
revised and signed into law May 7, 2008 (Public Law
29-71). Article 5 includes the rules for an advanced practice
registered nurse (APRN). An APRN is defined as a RN
who is authorized by the board to perform ANP as a certified nurse practitioner (CNP), CNM, CRNA, or CNS.
Scope of practice for APRNs is in accordance with
the functions and standards of the respective national
certifying organization for each category. All APRNs in
Guam are required to practice in accordance with protocols
developed in collaboration with and signed by a physician
licensed to practice in Guam. The board must approve a
collaborative agreement between the APRN and physician.
The collaborating physician provides consultation and
agrees to periodic review of the services being provided
by the APRN. The agreement must include a written
protocol to be used by the APRN for the management

82 Unit 1 The Evolution of Advanced Practice
in addition to a wide range of public health services. The
86-bed hospital is staffed with three NPs, one CNM, and
four midwives. Rota and Tinian also have health centers
that are part of the CHC. A NP, one of 31 health center
personnel on Tinian, has been the only medical provider
for more than 10 years.
The CNMI Board of Nurse Examiners is the autonomous public agency known as the Board of Nursing. The
governor appoints this regulatory body of nurses. The
Administrative Rules of the Board of Nursing (Subchapter
140-60.1), also known as the NPA, were most recently
revised and signed into law in May and June 2014. A NP
serves on the Board of Nursing and has helped model the
NPA for full practice autonomy.
An APN is defined as a RN who is authorized by the
board to perform ANP as a CNP, CNM, CRNA, or CNS.
Scope of practice is in accordance with the functions and
standards of the respective national certifying organizations for each category. Before 2007, many APNs were
certificate graduates and were grandfathered into the NPA.
Since January 2007, a minimum of a masters degree in
nursing is required. Documentation requires verification
of graduation and certification in population foci of the
education program and qualifications for prescribing. The
scope of practicefor a NP includes nursing functions as well
as advanced assessment, diagnosing, primary care provider
status, and admitting privileges for the hospital and other
health-care services. NPs are independently responsible
and accountable for the continuous and comprehensive
management of a broad range of health care. The NPA
scope of practice includes prescribing, ordering, dispensing,
and administering therapeutic devices including legend
drugs and controlled substances (PL 14-62 Section 2304)
consistent with the definition of the practitioners specialty
category and scope of practice (L. Lorenzo, personal
communication, July 30, 2016).
American Samoa (AMS) is the southernmost territory
of the United States with a total land area of 76.8 square
miles, slightly larger than Washington, DC. The 2010
population of 66,000 qualifies AMS as rural. The health
infrastructure consists of one hospital, five PHC centers,
and a VA clinic. The U.S. federal match for Medicaid
services is capped and the AMS government cannot bear
the burden of paying for coverage beyond the match.
Men and women from Guam serve in the U.S. Army
reserves. When not serving overseas in active duty or
deployments, these veterans receive health care from the
VA Clinic located in Guam. As of July 2016 there are
two physicians, one psychiatrist, and one NP in addition
to RNs, LPNs, and health technicians. Psychiatrists and
APRNs from the United States have also served there for
short periods because recruitment is a continual challenge.
The University of Hawaii School of Nursing (UHSON)
and Veterans Administration (VA) in Hawaii collaborated
on an interprofessional training opportunity at three rural
VA sites: AMS, Guam, and Hilo, Hawaii. These sites
were chosen because of the rural isolation and challenge
of recruiting skilled and culturally competent health-care
professionals. The goal is that they will ultimately choose
to serve in these locations. The DNP program director
from UHSON and the director of education at Hawaii
VA collaborated to implement this grant program. The
initial Rural HealthTraining Initiative (RHTI) grant was
written as a 3-year pilot project that began in 2013. The
UHSON sent students to Guam all 3 years (20132015)
with a total of three students. The grant was renewed in
2016 with plans to send more students.
Interest in APN in Guam is increasing. In 2010 there
were only a handful of APRNs including two to three
NPs. As of July 2016 seven NP students were enrolled in
a distance education program in Guam, but they faced a
real challenge because of a limited number of preceptors.
The GRMC has five NPs working in their emergency
department. The GMH is now considering changing their
hospital regulation to potentially hire NP hospitalists. There
are six NPs at the GNH. Several NPs work at Guam Public
Health and one in the Veterans Administration Clinic
(L. Lorenzo, personal communication, July 29, 2016).
Northern Mariana Islands
The Northern Mariana Islands, officially the Commonwealth
of the Northern Mariana Islands (CNMI), are located in
the northwestern Pacific Ocean. CNMI is one of two U.S.
territories with commonwealth status (the other being Puerto
Rico). According to the 2010 census 53,883 people were
living in the CNMI with the majority of the population
living on Saipan, Tinian, and Rota.
The Commonwealth Health Center (CHC) on the
island of Saipan is the only provider of comprehensive
health-care services for theisland and includes one hospital

Chapter 5 Global Perspectives on Advanced Nursing Practice 83
An anticipated dramatic increasein the aging population in
Japan and a shortage of physicians led faculty at Oita University
of Nursing and Health Sciences (OUNHS) in Japan to stress
practice-oriented nursing education at the graduate level.
The aim of the promotion of academic education was to
contributeto a health-caresystem that can provide patients
in Japan with safe and timely opportunities for health care.
With this in mind the Graduate School of Oita University
established a course in 2008 to educate NPs in its masters
program. This was the first such course in Japan, and the
March 2011 graduates of the masters program becameJapans
first NPs (Fukuda et al, 2014; OUNHS, 2016).
There are two NP majors in the fields of primary care
with separate curricula in the Oita University Graduate
School: the Geriatrics major, established in 2008, and
the Pediatrics major, established in 2009. The objectives
of the new majors are to train highly qualified NPs with
higher levels of expertise and competence in practice
who can contribute to clinical care in medical long-term
care facilities in remote areas and work autonomously
in collaboration with physicians (OUNHS, 2016). This
program development provided momentum to move the
government to amend the nurse practice laws. Policy and
legal changes are needed to delineate the scope of practice
for advanced practice nursing and to providethefoundation
for NP education (Fukuda et al, 2014).
In order to support the establishment of a NP system
in Japan, the Japanese Nurse Practitioner Association was
established in 2008. The aims of the association are to
standardize educational programs for NPs, to guarantee
the quality of their performance, and to work for social
understanding of thetitle of NP in Japan (OUNHS, 2016).
Following the initiation of the NP course by OUNHS,
the university project team also submitted an application
in collaboration with Oita Oka Hospital to arrange for a
designated administration district system. In the system,
NP students and graduates would be allowed to perform
some of the designated activities for hospital patients
under the supervision of and with physician orders. In
addition, in 2013 the Ministry of Health, Labour and
Welfare introduced plans for a new education system. The
bill for the amendment of the nursing service law had not
been changed for 66 years. Legislative discussions commenced in February 2014 with a hope for legal changes
(Fukuda et al, 2014).
AMS Chapter 10 laws include the health services regulatory board, which includes any practice of medicine,
dentistry, or nursing. The board is appointed by the governor
and composed of the director of health, one physician,
the public health officer, the director of nursing services,
a medical officer, a dentist, a LPN, and a representative
from the AMS community college nursing program. At
least 50% of the board,excluding the chairperson, must be
American Samoan. The board may carry out its functions
through the use of committees that specialize in health
services such as nursing, medicine, and pharmacy. The
Nursing Committee establishes licensing and treatment,
prescription, and other functions in collaboration with a
physician or osteopath with established protocols, regulations, and process of licensure.
The practice of advanced registered nursing (ARN)
means the performance of advanced level nursing actions
by a nurse midwife, a NA, or a NP must have certification
within the scope of practice and postbasic specialized
education, training, and experience. The ARN may perform actions or nursing diagnosis and nursing treatment
of alterations of health status. In addition, an ARN may
perform actions of medical diagnosis, treatment, prescription, and other functions that are identified by their
certification specialty in collaboration with physicians or
osteopaths. The collaborating parties may establish by
protocol higher levels of collaboration for specific acts or
specific circumstances.
American Samoa participated in a 3-year RHTI offered
to three sites in the WPR (refer to the section on Guam).
A total of nine students from UHSON participated in
this project (20132015) based in Samoa with plans to
send more based on additional funding.
Setting precedence, a native from independent Samoa
(Western Samoa) is the first Samoan NP to achieve a PhD
in nursing and also earn her DNP. Therefore, she was
bestowed the family title of a Faamatai (chief ). Faamatai
is the key sociopolitical system of governance and way of
life (faa Samoa) in Samoan culture. As a faculty member
she has served as a preceptor for NP students from the
UHSON for the VA RHTI. In addition, she and her
students live in AMS villages and serve at the VA clinic
providing health-careservices. One of the UHSON Samoan
students plans to return, after graduation, to establish a NP
practice in AMS (L. Lorenzo, personal communication,
July 29, 2016).

84 Unit 1 The Evolution of Advanced Practice
consultation in 2015 regarding this stipulation, the Nursing
Council has recommended changes that broaden the NP
scope of practice and remove the requirement that restricts
NPs to a specific area of practice. In 2016 a new scope
of practice statement was introduced. The new scope of
practice follows:
Nurse practitioners have advanced education, clinical training
and the demonstrated competence and legal authority to practice
beyond thelevel of a registered nurse. Nurse practitioners work
autonomously and in collaborative teams with other health
professionals to promote health, prevent disease, and improve
access and population health outcomes for a specific patient
group or community. Nurse practitioners manage episodes
of care as the lead healthcare provider in partnership with
health consumers and their families/whanau. Nurse practitioners combine advanced nursing knowledge and skills with
diagnostic reasoning and therapeutic knowledge to provide
patient centred healthcareservices including the diagnosis and
management of health consumers with common and complex
health conditions. They provide a widerange of assessment and
treatment interventions, ordering and interpreting diagnostic
and laboratory tests, prescribing medicines within their area
of competence, admitting and discharging from hospital and
other healthcareservices/settings. As clinical leaders they work
across healthcare settings, influence health service delivery
and the wider profession. (
NP candidates can focus on a specialty area of practice;
however, this designation no longer appears on the register
or on their practicing certificate. There will be a transition
period to incorporate these changes and issues associated
with the role of the Nursing Council of New Zealands
approval of educational programs.
Requirements to become a NP in New Zealand are
the following:
Registration with the Nursing Council of New Zealand
(the Council) in the RN scope of practice
A minimum of 4 years of experience in a specific area
of practice
The completion of an approved clinical masters degree
program that includes demonstration of the competencies for advanced practice and prescribing applied
within a defined area of practice of the NP. The program
must include relevant theory and concurrent practice
As of May 2016, there was no official professional
designation of NP yet in Japan even though the Japanese
Organization of Nurse Practitioner Faculties (JONPF)
provided the certifying examination for the graduates
from seven NP programs. Nursing and medical societies
have opposed the policy and legal changes supportive of
advanced practice nursing. Therefore, the activities of
graduates from the NP programs depend on the physician
in the institution where the graduates work (M. Suzuki,
personal communication, May 9, 2016).
New Zealand
ANP was initially recognized in 1988 in New Zealand at two
levels. The New Zealand Nurses Organizations (NZNO)
credentialing process certified nurses as nurse-clinicians
or nurse consultants (clinical). Once the NP model was
introduced in 2000, NZNO phased out and ceased its
certification process in 2006 when regulation of NPs came
under the jurisdiction of the Nursing Council of New
Zealand (NCNZ) (S. Trim, personal communication,
March 11, 2008).
A task force established in 1997 studied barriers to
nursing practice and recommended the development of an
advanced role. The NCNZ then set up a working group
to develop a regulatory framework. Following significant
consultation, a framework was agreed upon and published
(NCNZ, 2001). The framework presented in 2002 and
updated in 2014 included standards for the approval of
specific masters programs and process for such approval,
a title (NP), role competencies, and a description of the
role and a process for endorsement (NCNZ, 2014).
The applicant formally applies to the council and must
present a portfolio that includes a curriculum vitae, transcript ofeducation preparation, research, publications, and
evidence of clinical practice that includes descriptions, case
studies, case notes from assessments, and endorsements
of practice. The panel interview includes a presentation
by the applicant describing relevant clinical practice and
a response to panel questions that include clinical vitae
and scenario testing (NCNZ, 2014).
The first NP in New Zealand was endorsed in late
2001. Initially title protection was achieved through
trademarking; however, the trademarking concept is no
longer in place. Before 2015 NPs in New Zealand were
required to choose a specific area of practice that was then
placed on the register as a condition. Following extensive

Chapter 5 Global Perspectives on Advanced Nursing Practice 85
Program (NSCP), which was formally launched through
a Board of Nursing resolution in 1999 (Board of Nursing
Resolution, 2002). Nursing leaders introduced the Nursing
Specialty Certification Council, which credentials nurses
and accredits organizations and educational programs
highlighting the practice of specialized nursing. This is
further enforced through the Comprehensive Nursing
Specialty Program stipulated under the Philippine Nursing
Law of 2002. Qualified nurses may be given certification
in three levelsNurse Clinician I, Nurse Clinician II,
and Clinical Nurse Specialistand may work under four
major groups of nursing specialties: Medical-Surgical,
Community Health, Maternal and Child Health, and
Mental Health/Psychiatry (Philippine Board of Nursing,
2008). These policies provide for an informal category of
nurses working in specialty areas across secondary, tertiary,
and specialty hospitals. These nurses may or may not be
credentialed under the NSCP. Most of these nurses are
prepared through formal or informal education within
their home institutions.
There are a large number of baccalaureate entry-level
programs for nursing in the Philippines with an emphasis
on education for export of its graduates, not only to the
United States but also to the Middle East. In the midst of
this situation, there are many masters degree programs in
nursing with most emphasizing degrees in administration
and at least three well-established nursing doctoral programs
in the country (V. M. Manila, personal communication,
June 18, 2016).
Currently, thereis no policy that formalizes the position
of an APN in the Philippines; neither are there explicit
standards of practice for those who may be working as
APNs. In most health institutions, the generalist and
specialty area nurses have the same job descriptions with
a similar sense of patient and professional accountability.
These developments provide the motivation to formulate
an APN framework in the Philippines that would define
systems, scopes, and standards of practice, and ultimately
contribute to better health for the public (V. Manila,
personal communication, June 18, 2016).
Even though the system for a role similar to advanced
practice nursing in the Philippines appears nonspecific,
a form of APN is stipulated in four major policies in
nursing: the Philippine Nursing Act of 2002 Article VI
Sec. 28 and Article VII Sec. 31, and in Board of Nursing
(BON) Resolution No. 99-13, 99-24, and 2002-118.
The completion of an equivalent program overseas,
a clinically focused masters degree qualification that
meets the previously specified requirement
Passing an assessment against the NP competencies by
an approved panel
(NCNZ, 2014)
Prescriptive authority in New Zealand. The Medicines
Amendment Act of 2013 designated NPs as authorized
prescribers. The Misuse of Drugs Amendment Regulations
of 2014 allow NPs to prescribe controlled drugs within
their scope of practice for:
Up to 1 months supply for Class A and B controlled drugs
Up to 3 months supply for Class C controlled drugs (http://
Before July 1, 2014, NPs may have been registered
without prescribing authority. From July 1, 2014, this
group of nonprescribing NPs has a stipulation in the
NP scope of practice identifying they are unable to
prescribe. The stipulation reads must not prescribe as
an authorized prescriber (NP). Nonprescribing NPs
can achieve prescribing competency by either of the
following pathways:
Those with qualification that includes pharmacology
and a prescribing practicum are required to complete
100 hours of supervised prescribing practice and a
competence assessment by a medical mentor and a NP
Those NPs who do not havethe appropriate qualification
must complete a Nursing Council approved pharmacology
paper and a prescribing practicum that includes 100 hours
of supervised prescribing practice and a competence
assessment by a medical practitioner and a NP or supply
a portfolio that demonstrates theequivalent knowledge
and skills and complete a panel review
Nurse Practitioners New Zealand (NPNZ) is an organization
that aims to offer a collective voice and act as a resource
for the advancement of NP practice in the country (http://
Advanced practice nursing in the Philippines is partly
recognized through the Nursing Specialty Certification

86 Unit 1 The Evolution of Advanced Practice
in the projects. The action plan included terms of reference
for an oversight committee and key activities to initiate
the project. CCNN planned an ANP program from May
2015 to May 2017, focusing on the education and a career
development pathway for APNs (Hill & Parker, 2015).
Nursing in PR China is currently evolving toward
increased professionalization. APNs with postgraduate
education qualifications are an important component of
this progress. In 2014 the Chinese Ministry of Education
(MOE) approved 58 new clinical/professional masters of
nursing programs. This means there will be more clinical
nurses with a masters degree. The ANP program is being
initiated to contributeto this advancein nursing. A Chinese
ANP program Executive Committee composed of nursing
deans from Fudan University, Peking Union Medical College,
and Peking University and nursing directors from affiliated
hospitals has been established to facilitatethis process. This
plan for nursing is consistent with the central governments
10-year plan to increase clinical training of physicians
(M. Hill, personal communication, January 16, 2016).
The National University of Singapore, under the auspices
of the Yong Loo Lin School of Medicine, established an
APN program in Singapore in 2003, offering academic
preparation in acute care, adult health, and mental health,
while viewing the course of studies as generic in emphasis.
As of 2016 specialty offerings have expanded to critical
care, oncology/palliative care, and pediatrics. Following
graduation from the 2-year full-time masters program,
students must completethe minimum of a 1-year internship
in their specialty before applying for certification, licensure, and registration with the Singapore Nursing Board
(SNB). Registration to practice as an APN is renewed on
an annual basis with the SNB.
The APN Register established in 2005 by the Ministry
for Health is expected to help with the systemic development of this category of clinical nurse, educated to
a masters level in nursing, in becoming a key player in
Singapores drive to keep health care affordable while
maintaining high-quality services. Consistent with this
view and to support developing professionalism for
nursing, the Ministry of Health established a clinical
nursing career path that includes the APN roles. The
clinical career track is similar to those that exist for
management and education.
The Nursing Act Article VI Section 28 enlists the scope
of the nurse to include advanced nursing practice. A
study conducted to evaluate coherence and outcomes to
these policies and their relevance to ANP (Manila, 2013)
revealed the following findings:
Nurses in the Philippines function in specialized practice
but with limited role expansion.
Education for advanced practice is fragmented.
There is an absence of a standard of advanced practice
across institutions.
There are notable similarities but foundational gaps
compared with international APN frameworks.
Thesestudy findings contributed to the drafting of the new
nursing bill which, as of June 2016, was being processed
for new legislation that will incorporate a provision to
include the term and position of advanced practice nursing.
When signed into law the hope is that APN roles will be
fully realized in the Philippines (V. M. Manila, personal
communication, June 18, 2016).
Peoples Republic of China
Advanced practice nursing roles are informally being
implemented across the Peoples Republic of China (PR
China) in recognition of the need to expand the scope
of nursing practice to meet changing population and
health-care delivery needs. The Chinese government
noted this situation and has given approval for clinical/
professional degrees at the masters level aimed at training
nurses to develop advanced practice competencies. By
2011 28 universities in PR China had recruited nursing
students into clinical/professional degree programs in various clinical areas indicating a new developmental phase in
graduate nursing education in PR China. In 2014, 58 new
clinical/professional masters programs were approved. The
total number of clinical/professional masters programs in
nursing reached 84 by the end of March 2015 in China
(Hill & Parker, 2015).
In 2015 the China Medical Board China Nursing
Network (CCNN) sought expertise from Australian
and American consultants for the development of the
Chinese ANP program. Key recommendations included
development of curricula for a clinical master of nursing
program, suggestions for development of standards for
APN roles, and a proposal to consider implementation of
pilot projects with educated specialty nurses participating

Chapter 5 Global Perspectives on Advanced Nursing Practice 87
practice under the Medical Service Law. A special law for
agriculture approves the CHNP for practice as a nurse
Discussions attempting to clarify issues related to
APNs began in the 1990s. In 2003, the medical law
revision identified qualifications for the APN and designated 13 areas of specialization. Qualifications include
masters-level education, passage of the certification
examination, and experience in a chosen specialty. The
first certification examination was given in 2005 (J. Kang,
personal communication, 2007). As in many countries,
the Korean Nurses Association faces difficulty obtaining
consensus from the nursing community on scope of
practice, educational requirements, and titling (Schober &
Affara, 2006; Sheer & Wong, 2008).
While the APNs have also existed in the country for
more than 20 years, a strong value of the physician role has
inhibited the professional respect to allow APNs their own
autonomy and peer collaboration. Lack of local support
in Korea is represented by the fact that there is only one
hospital in the country that employs APNs in the NP-like
role, and even then the position reflects more of a senior
nursing position (Maryland Nurses Association, 2012).
Taiwan has a long history of nursing education and practice
evolving from apprenticeship hospital-based programs to
academic professional education in institutions of higher
learning. Following the countrys release from Japanese
rule in 1945, nursing rapidly evolved in its development
of university programs. The first masters of science (MS)
program was started in 1979, with the first doctoral program in nursing offered in 1997.
In 1990 NPs werelisted along with professional nurse
as a legal position in nursing. In 1991 the Nurses Act was
passed in an attempt to alleviate the nursing shortage and
allow nurses to practice independently. NP programs were
started in 2000 after an amendment to the Nurses Act
made the NP title official (Chao, 2008). With passage of
Paragraphs 3 and 4 of Article 23 of the Nurses Act, NPs
became legally able to provide care (Chin et al, 2015). In
general, practice guidelines allow NPs to practice more
independently under hospital approval. NPs also can extend
their practice to other institutions or community-based
facilities; however, as of July 2016 the description for that
possibility was unclear.
To renew the APN practicing certificate (PC), APNs
must fulfill the requirements stipulated by the SNB to
demonstratethat they have maintained their competency.
Requirements include achievement of a minimum number
of clinical hours related to their level of practice and years
postcertification plus acquiring 30 Continuing Education
(CE) points in every qualifying period (QP) in categories
as stipulated by the SNB.
Key decision makers in education, policy, and administration are working to adapt models and frameworks from the
United Stateswhile at thesametime attempting to introduce
APN roles to the public that are suitable for hospital and
community settings in the country.Visibility and support for
this advancement in nursing areevidenced up to the Ministry
of Health level,where a requestwas madeto have 200 APNs
in placein various specialties in Singapore by 2014 (Ayre &
Bee, 2014).In 2015 therewere 172 registered APNs, mostly
in the public sector in Singapore (MOH, 2016).
Republic of South Korea
It could be said that NP-like nursing roles have been in
place in Korea since the time of the medicine lady in
the 15th century. Care provided by the medicine ladies
included deliveries, physical examinations, acupuncture,
and prescribing of herbal medicines (J. Kang, personal
communication, November 15, 2007).
CHNPs have been providing comprehensive primary
health-care services in rural communities of South Korea
since the health-care law for provision of health care for
rural residents was legislated in 1980. CHNPs provide
PHC to approximately 28% of the rural population in
South Korea; however, this number is decreasing becauseit
is more difficult to attract nurses to work in the rural areas
(J.Tang, personal communication, November 15, 2007).
Haho Clinic, located 2 hours from Seoul between Yoju
and Ichon, has provided clinic services for the community
and the surrounding area since 1985. The scope of practice
for the CHNPs includes diagnosis, prescriptive authority,
and referral to other practitioners. In addition, home visits,
health education, disease management, immunizations,
school health services, and care for the elderly are part of
the health-care service provision with additional support
from nurses and community helpers. The nurse specialist
system was formalized in Korea to fulfill changes in the
medical environment. Anesthesia, public health, mental
health, and home health-care nurses are approved for

88 Unit 1 The Evolution of Advanced Practice
has a beginning with guidelines that have been established
to ensure that nursing graduates will have sound preparation to provide quality care in Taiwan (R.T. Goodyear &
S. F. Tsay, personal communication, June 23, 2016).
West Java, Indonesia
The Indonesian government and nursing associations have
made efforts to enhance the professionalism of nursing
through improvements of a higher degree of nursing education. Since 1985, nursing in Indonesia has moved from
vocational to professional status through the opening of
the first baccalaureate degreein the University of Indonesia
(UI). In 1994, another baccalaureate program in nursing
was opened at Universitas Padjadjaran (UNPAD) in West
Java Province. Following the opening of baccalaureate
programs, the UI opened the master of nursing programs
that were integrated with specialization programs in 2003.
Thesespecialization programs consist of community nursing,
maternity nursing, medical surgical nursing, psychiatric
nursing, and paediatric nursing (Simamora, 2009). In
Indonesia, masters of nursing and nursing specialization
programs are dissimilar. The masters degree focuses on
academics and research, whereas specialization programs
focus on practice. The Universitas Padjadjaran has established a masters of nursing in critical care nursing and
community health nursing in 2009, followed by a masters
program in medical surgical nursing, nursing management,
psychiatric nursing, and paediatric nursing. The University
of Indonesia has been the only university in the country
offering both masters and specialization programs. However,
the specialization programs at UNPAD are planned to be
established in 2017 and will include critical care nursing
and community health nursing.
Indonesian nurses havethe opportunity to open a private
nursing practice that has been supported by regulation of
the Ministry of Health since 2010. Moreover, in 2014,
Indonesia has a Nursing Act that strongly supports private nursing practice. With advanced nursing education
programs, the Indonesian government expects that the
improvement of level of education can contribute to the
improvement of nursing practice; however, the development
of advanced practice nursing in Indonesia is relatively
slow. No publications were found in July 2016 regarding
the numbers of APNs in Indonesia nor the factors that
contribute to the slow development of this practice. One
possible explanation is that most of the students of the
NPs have been educated in hospital training programs
since the 1990s in an attempt to alleviate the shortage of
physicians and lessen their workload. However, the NPs
were functioning at first without guidelines and standards.
The Department of Health (DOH), in conjunction with
the National Health Research Institute (NHRI) and the
Taiwan Association of Nurse Practitioners (TANP), has
established standards for approving programs, curriculum
guidelines, and preceptor guidelines. NP preparation remains predominantly based in hospitals with the faculty
made up of physicians and health providers from other
disciplines and the education focused on the medical and
surgical domains. Even though the NP education model is
still mainly hospital-based there are developing programs
such as an academic model at Taiwan University and
possibilities for education abroad. If participants achieve
completion of those approved education programs, they
can apply for the national examination to obtain an NP
practice certificate.
The main work settings for NPs are in acute care
hospitals with some positions in emergency room and
ambulatory care settings with the possibility to extend
their practice to long-term care. Continuing education is
required for a NP to apply for a 6-year extension of the
certification period. As of 2008 there were 857 certified
NPs in Taiwan. Similar to other countries, certified NPs
in Taiwan are seeking additional academic preparation to
achieve professional status and credibility in their work
settings and among professional colleagues. Several schools
of nursing within universities are responding by offering
masters-level NP programs. Additional universities are
offering post-NP certificate transition programs toward
a masters in nursing. There is a Taiwan Association of
Nurse Practitioners. As of July 2016 there were association
photos available with text only in Thai.
In a country with a NHI system that enrolls 99% of its
citizens, it is estimated that there will be a health problem
associated with an increase in the aging population that
is expected to reach 4.76 million by 2026 (Tsay & Kuo,
2008). In response to the lack of medical labor the Ministry
of Health and Welfare is deliberating a supportive measure
to increase the number of NPs on a yearly basis (MOHW,
2014). Health promotion, disease prevention, integrated
health care, and chronic disease management are all areas
of upcoming need that will be addressed by nurses with
advanced knowledge and skills. Advanced practice nursing

Chapter 5 Global Perspectives on Advanced Nursing Practice 89
and challenges as leaders attempt to activate schemes
that will ultimately change the profile of the health-care
workforce and delivery systems. Role ambiguity and
confusion regarding titling, scope of practice, educational
preparation, and credentialing present questions that
must be addressed.
For ANP to thrive in health-care systems globally, the
authors believe that several areas need to be confronted
and managed successfully. A well-developed scope of
practice that engages APNs in a wide range of activities
including health-care planning and policy development,
in addition to health promotion, disease prevention, and
diagnosis and treatment of illness, isessential. This involves
the ability to embrace the diversity of health-care systems
worldwide without losing ANP core characteristics. An
international consensus on who an APN is and how the
ANP concept fits in the health-care workforce would assist
in speaking to the recurrent topic of role ambiguity. In
addition, it is vital that any progress toward consensus
take into consideration country-specific nursing, health
care, and policy cultures.
Challenges lie in the capacity of ANP advocates and
decision makers to achieve consistency across clinical and
educational models. Continually evaluating and reviewing
practice by adding competencies that reflect dynamic
changes in health care and role development is fundamental.
Increasingly, APNs will be asked to provide evidence that
they are a cost-effective, valued, and sustainable addition
to health-care teams and provision of health-care services.
Research that provides evidence demonstrating the ability
of APNs to provide care in partnership with patients and
their families, within communities, and in collaboration
with other health-care professionals will provide a strong
foundation for the addition of this role to comprehensive
health-care services.
specialization programs are lecturers who use their specialization skills to teach students, not to practice. Lecturers
have difficulty practicing because of their high load of
academic work. Therefore, a nursing centre (NC) model
was established in West Java, Indonesia.
The NC model in West Java, Indonesia, is defined
as a nurse-led clinic that integrates health-care services,
education, and research through the optimal usage of
all potential resources in the community health-care
system (Samba, 2007). This NC is unique because it is
co-located in the government-owned community health
centers and places an emphasis on improving the quality
of community health nursing services, education, and
health outcomes for people in the community. A doctoral
study (Juniarti et al, 2015) of the NC model in West Java,
Indonesia, demonstrated that the NC model has made a
positive change for nursing practice as well as people in
the community (N. Juniarti, personal communication,
July 25, 2016).
Descriptions of APN development in various countries and
research reported in theinternational literature confirm the
benefits of ANP and support the view that advanced nursing
roles are feasible, sustainable, and provide high-quality,
competent health care. Legislation and regulations often
lag behind actual practice. Disagreement exists between
practice acts of various health-care professionals and progress supportive of ANP seems, at times, more similar to
an intricate maze or puzzle than a picture of coordinated
forward motion.
International momentum supportive of APN services
is increasing; however, initiatives often face obstacles

The Practice Environment

Advanced Practice Nurses
and Prescriptive Authority
Jan Towers
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Discuss advanced nursing practice and prescriptive authority.
Summarize the evolution of prescriptive authority for advanced practice registered
nurses (APRNs).
Discuss the patterns of statutory and regulatory policy currently governing
prescriptive authority for APRNs.
Describe obstacles to achieving plenary prescriptive authority for APRNs.
Explain the statutory and regulatory changes necessary to achieve plenary
prescriptive authority.
Distinguish prescriptive authority among nurse practitioners (NPs), clinical nurse
specialists (CNSs), certified registered nurse anesthesiologists (CRNAs), and
certified nurse-midwives (CNMs).
Predict the future of prescriptive authority for APRNs.
As professional nurses expanded their role to cross into
traditional medical domains, the ability to prescribe
medications became increasingly important. Although
certified registered nurse anesthetists (CRNAs), certified
nurse-midwives (CNMs), and clinical nurse specialists
(CNSs) had practiced in advanced roles for some time
before the birth of nurse practitioners (NPs), the advent of

Chapter 6 Advanced Practice Nurses and Prescriptive Authority 93
NP practice in primary care influenced the authorization
of all advanced practice registered nurses (APRNs) to
prescribe medications. Before that time, CRNAs selected
and administered anesthesia, but not other medications.
Likewise, CNMs traditionally focused on childbirth and
did not require extensive prescriptive authority. CNSs
functioned in advanced practice nursing roles with diagnosed patients who were under the care of a physician.
Although professionals in each of theseroles madejudgments
regarding medications used by patients under their care,
they relied mainly on physicians to provide prescriptions
for medications when they were needed.
Nurse Practitioners and Prescriptive
As NPs began to provide primary care services, they used
these same traditional processes to provide medications
for the patients that they served. Although primary care
practice places an emphasis on health promotion and
disease prevention, most patients coming for primary care
services do so with a health problem for which they are
seeking assistance. As time went on, it became evident that
depending on physicians to prescribe medications created
problems in the areas of patient access to care, continuity of
care, and patient flow. When providing primary care, NPs
assessed and diagnosed patients who needed prescription
medications and treatments for their care.
The inability to sign ones own prescription, even if
a physician was on site, was inconvenient for the NP,
physician, and patient alike. It caused interruptions in the
physicians interactions with patients, unnecessary delays
each time NPs had to wait to get signed prescriptions from
physicians, and often interfered with the credibility of NPs
by rendering them dependent on physician signatures for
medications that were being ordered based on their own
diagnostic decision making. These problems were exacerbated when a physician was not on site. Patients then had
to wait for prescriptions to be signed before they could be
filled. If a physician was not availablefor a day or more, the
implications for patient safety and health care wereserious.
Methods were found to get around this stumbling
block, such as calling prescriptions in to pharmacies or
using other more questionable methods for obtaining a
physician signature on the prescription so that the patient
could pursue treatment in a timely manner. The need for
the authority of NPs to prescribe under their own names
became evident and pressing.
In the early days, NPs did not have title recognition
other than that of registered nurse (RN) in their state regulatory systems. They were not alone; with the exception
of CNMs and CRNAs in several states, no APRNs had
title recognition in statutory or regulatory language in the
state nurse practice acts or administrative rules. Likewise,
there was no authority to prescribe medications. In fact,
many nurse practice acts clearly prohibited the prescribing
of medication by nurses regardless of specialty or status.
Thus began the long journey of convincing legislators and
regulators to change state statutes and regulations to give
title recognition and prescriptive authority to APRNs.
Because licensure for all professions occurs at the state
rather than thefederal level, the movement to achievethese
goals moved unevenly, as states with the most need moved
forward to make changes. The movement was enhanced
in the early days by an acute shortage of primary care
physicians, and somestates with higher primary care needs
moved forward morerapidly than others. At that time, rural
states were more likely to initiate statutory and regulatory
adjustments than werestates with large urban populations.
Convincing decision makers in thestates was not without
its problems. Then, as now, NPs had to demonstrate that
they had the knowledge baseto safely diagnoseillnesses and
prescribe medications.This meant thateducational programs
had to demonstratethat their curriculums prepared NPs for
an independent prescribing role. Advanced pathophysiology
and pharmacology and the development of differential
diagnosis and clinical decision-making skills needed to be
visible in the programs. With the advent of federal grants
to prepare NPs, the content and quality of the preparatory
programs was increasingly standardized.
In addition, to be credible in health-care systems, it
was necessary for members of the medical community
to advocate for the recognition of these professionals
and their ability to prescribe medications independently.
Many did, and through this window of opportunity NPs
began to gain prescriptive authority state by state over
subsequent years.
Initially, the authority to practice and prescribewaslimited.
In many of the early states where some form of prescriptive
authority was conferred, boards of medicine and boards of
nursingwere authorized to jointly promulgaterules and regulations governing NP actions, including prescriptive authority.

94 Unit 2 The Practice Environment
In 23 of these jurisdictions the prescriptive authority is
plenary (NCSBN, 2016).
Other factors that have assisted in this endeavor
include an enthusiastic consumer population, especially
pregnant women, who spread the word about the skills
of CNMs. They have often packed hearing rooms and
legislative chambers, bringing their babies and children,
providing testimony regarding the worth and skill of the
services provided to them by CNMs. CNMs have the
same state-to-state variability regarding authorization to
prescribe controlled drugs and required relationships, if
any, with physicians.
Clinical Nurse Specialists
and Prescriptive Authority
CNSs have more recently felt the need to prescribe medications for the patients they serve. Those particularly
desirous of the authorization are the psychiatric and
mental health CNSs who often have their own practices
or function autonomously in mental health clinics and
other specialty practices. The prescriptive authority need
for practitioners in this field is particularly acutein agencies
serving vulnerable populations.
Theremainder of the CNS community has mixed responses
to the need for authorization to prescribe medications.
At the core of this ambivalence is the role played by the
CNS in the employment setting, the scope of prescriptive
authority needed when working in a particular specialty with
patients who have already been diagnosed, theeducational
preparation required to allow for this authorization, and
therisk of being unnecessarily placed under thesupervision
of physicians in states where such supervision is required.
Some states do not provide title recognition for CNSs.
There has been controversy regarding whether an additional
title recognition is actually needed for CNSs. Therefore,
theissue of prescriptive authority for CNSs has been more
cloudy than that of NPs or CNMs (National Association
of Clinical Nurse Specialists [NACNS], 2002).
Nevertheless, CNSs have begun to obtain title recognition (often driven by the need for recognition to receive
reimbursement for services) and the authority to prescribe
within their scope of practice. Currently, two-thirds of the
states authorize CNSs to prescribe medications in onefashion or another, and 29 offer plenary authority (NCSBN,
2016). Variability in recognizing who may qualify, scope
Statessuch as NorthCarolina and Idahowere among the first
stateswith jointly promulgated rules. Even today a fewstates
still fall under the regulation of both boards of nursing and
boards of medicine. Some of thosestates (wherethe highest
degree of controversy over scope of practice has traditionally
existed) arelimited to jointregulation of prescriptive authority.
Recent attemptsto changethatregulatory pattern have been
harder to achieve. Pennsylvania is the most recent state to
move away from joint promulgation of rules to regulation
solely by the board of nursing.
Initially, NPs were authorized to prescribe a limited
number of medications under physician supervision.
North Carolina was one of the first states to develop a
limited drug formulary. Subsequently, states developed
combinations of formularies and physician oversight
under jointly promulgated rules or under rules developed
by boards of nursing. The form of those rules depended
largely on the persuasiveness of NPs and the attitudes of
the legislators and governors of those states.
Currently, NPs prescribe legend drugs under their own
signature in all 50 states and the District of Columbia. In
addition, they prescribe controlled drugs in 48 states and
the District of Columbia. Variation exists among states
in the area of the authorization to prescribe controlled
drugs and the relationship, if any, that must be maintained with a physician. Currently, there exists plenary
prescriptive authority (no requirement for any physician
involvement) in 22 jurisdictions (states) including the
District of Columbia (National Council of State Boards
of Nursing [NCSBN], 2016).
Nurse-Midwives and Prescriptive Authority
CNMs have had to undergo the same process as other
APRNs to attain prescriptive authority. Because their
educational preparation and role developed to include
not only obstetrical and newborn care but also the general
health management of their patients, the need to prescribe
a broader range of medications also increased, making the
previously described arrangement for prescribing under
the physicians signature unreasonable.
Federal funding of CNM educational programs helped
to implement the standards established by this discipline
and facilitate the passage of statutes and rules that allow
them to prescribe in 50 states and the District of Columbia
with variable limitations in the area of controlled drugs.

Chapter 6 Advanced Practice Nurses and Prescriptive Authority 95
to prescribe and prove that prescribing by APRNs was
safe and contributed to the well-being of the population.
There are a variety of ways to authorize prescriptive
authority within a state. Changes (amendments) may be
made to nurse practice acts (statutes), new statutes may
be developed separate from nurse practice acts, or changes
may be made in states administrative codes through the
development of regulations promulgated by the appropriate
regulating board (in most cases the board of nursing).
In the case of new statutes or statutory changes, legislation must beintroduced that amends or adds to current
law to give title recognition and prescriptive authority
to APRNs (NPs, CNMs, CNSs, or CRNAs). Once legislation is introduced, it is referred to a committee of
jurisdiction (usually a professional licensure committee)
for consideration. Once the legislation is in committee,
the chair of that committee generally calls for a hearing
to allow proponents and opponents of the legislation
to give testimony regarding the introduced legislation.
After hearings are conducted, at the chairs discretion,
the committee votes on the legislation and passes it out
of committee. In some states, proposed legislation must
also go through the appropriations committee of at least
one of the voting chambers to determine cost and evaluate
the fiscal impact on the state. After passing through all
appropriate committees, the legislation, at the discretion
of the majority party leadership, is taken to the floor of
the voting chamber for a vote. Sometimes this is done
simultaneously in both chambers of the state legislature;
in others, the legislation passes through one chamber at a
time. Once the legislation has been agreed on (passed) by
both chambers of the legislature it is sent to the governor
to be signed or, in the case of some states, to be vetoed.
During this process language changes in proposed
legislation are often made or negotiated to satisfy other
interested parties. For this reason, thelanguage of authorizing
statutes varies to a certain extent from state to state. This
is particularly true in the sections (a) defining procedures
to be followed and requirements that must be met to be
recognized as an APRN; (b) defining the relationship,
if any, that must be held with a physician to prescribe;
and (c) determining the scope of prescriptive authority
of the APRN, particularly the authorization to prescribe
controlled drugs (schedules I through V). As statutes are
passed, much time and energy goes into attempting to
negotiate language that is acceptable to the advanced
of prescriptive authority, ability to prescribe controlled
substances, and required relationships with physicians
occur from state to state. In some states the statutes and
regulations are similar to those of NPs and in others they
are not. A few states have extended prescriptive authority
to psychiatric and mental health CNSs only. A few have
grouped all APRNs under one set of regulations, whereas
most have kept the four clinical groups separated under
an APRN umbrella that allows for regulatory variability
among APRNs in their states.
Nurse Anesthetists
and Prescriptive Authority
The authority of CRNAs to select and administer anesthesia
has long been recognized. Until recently, CRNAs have been
less involved in thestruggleto obtain prescriptive authority
than the other three disciplines. Somerepresentatives from
the CRNA community have maintained that ordering and
administering anesthesia does not fall under the rubric of
prescriptive authority in its traditional sense (American
Association of Nurse Anesthetists [AANA], 2016). Increasingly,
however, CRNAs are becoming involved in pain management of patients in the practices they serve and thus have
the need to prescribe. Currently, nurse anesthetists have
prescriptive authority in 30 states; 23 of those states still
require collaboration with or supervision by a physician,
and 28 award plenary authority (NCSBN, 2016). As with
the other APRN groups, CRNAs have found that they
haveto work to convincelegislators and governors of their
knowledge and skills. Their availability in rural areas has
enhanced their ability to obtain these privilegeseven in the
presence of opposition from the medical community. As
with NPs, CNMs, and CNSs, they have had to demonstrate
the strength of their educational programs and the safety
of their practice to obtain privileges in this area.
To alter state statutes and regulations, APRNs had to
educate state legislatures, executive officers, and regulators regarding the role of the APRNs they represented.
In addition, they had to demonstrate a need for APRNs

96 Unit 2 The Practice Environment
A negative or exclusionary formulary that allows the
APRN to prescribe all drugs with the exception of a
short list of forbidden drugs
An individualized collaborative formulary established
by the APRN with a collaborating physician
Unlimited authority with no formulary or collaborative
Regulator Established Formulary
An established formulary was used in the early days of
APRN prescribing activity to determine an agreed-on
list of drugs that APRNs could prescribe. As new drugs
came onto the market, updating of these formularies was
needed to allow prescribing according to current practice
standards. Although this quickly became a cumbersome
process, it is still in use today in a few states.
Negative or Exclusionary Formulary
Exclusionary formularies werefound to be a more practical
approach to regulation of prescriptive authority. By creating
a short list of forbidden drugs (e.g., chemotherapy, gold
treatments), the APRN had more flexibility in choosing
appropriate treatments for patients. This has been particularly important in the primary care setting.
Collaborative Formulary
More flexible than the established formulary and, to a
certain extent, more flexible than a negative formulary, a
collaborative formulary allows the APRN to create a formulary most useful to his or her practice in collaboration
with an identified physician who serves as a collaborator.
Although this has worked well in some states, in others,
where the formulary must be shared with the regulatory
board, it has sometimes become a nightmare. Requirements
regarding information to be included in formularies and
updating formularies can be, to say the least, cumbersome
and obstructive.
Open Formulary
The most flexible framework for prescriptive authority
is the open formulary, in which APRNs have no limitations regarding what they can prescribe. In these cases,
APRNs prescribe according to their own specialty scope
of practice, just as physicians prescribe within their own
scope of specialty practice. The majority of states that have
implemented this framework in their regulations have done
practice community, involved legislators, governors, regulatory bodies, and other interested parties. Once statutes
have been passed and signed by the governor of a state,
rules and regulations are developed and approved by the
authorized regulatory body or bodies.
When regulations are developed, they are first written
as proposed rules and are placed in a public register for
comment. The comment period covers a limited time, after
which the promulgating boards consider the comments
and make appropriate changes in the proposed rule at
their discretion before publishing a final rule. In most
states, such regulations must then be approved by some
arm of the legislature, often committees of jurisdiction,
sometimes by one or the other legislative chamber, before
approval by the governor. For this reason, APRNs and
regulatory bodies are often embroiled in negotiations
similar to those encountered in the legislative process that
result in alterations that make for variance in regulations
from state to state. These variations are in the same general
areas where there is variability in statute.
Because the purpose of state regulatory bodies, such as
boards of nursing, is to protect the public (in this case, the
public health), boards of nursing vary in their advocacy of
advanced practice roles in the regulatory process. In most
states governors appoint the members of the professional
licensure boards. Having APRNs who understand the roles
of NPs, CNMs, CNSs, and CRNAs appointed to these
positions can help the regulatory process when issues such
as prescriptive authority are considered.
Several states, rather than introducing or altering
statutes to authorize APRN prescriptive authority, have
instead developed and instituted regulatory changes in
the administrative code by which the advanced practice
disciplines must abide. Although regulation cannot override statute, statutes are often worded broadly enough for
regulations regarding title recognition and authorization
to prescribe drugs to be developed by the regulatory body
or bodies without disturbing statutes.
Patterns of Statutory
and Regulatory Authority
Four basic patterns of regulation regarding prescriptive
authority have evolved over time:
The use of an established formulary or lists of drugs
that the APRN can prescribe

Chapter 6 Advanced Practice Nurses and Prescriptive Authority 97
The roads traveled by APRNs to obtain prescriptive
authority have not been without struggle. There is no
denying that the majority of barriers to practice have
roots in organized lobbying by certain parts of the medical
community to limit the autonomy of APRNs. This move
has often been couched in the language of protecting
public safety. Therefore, some legislators and governors
have seen fit to set limitations in statutes and administrative rules governing APRNs. The literature is replete with
studies that report on the clinical safety of APRNs. In the
studies that have been conducted, patient safety has been
found to be as high with APRNs as with physicians and
often have been found to be higher with APRNs than
with physicians (Brown & Grimes, 1995; Laurent et al,
2006; Office of Technology Assessment [OTA], 1986).
The ratings on quality of care have also been consistently
high. APRNs, particularly NPs, have been studied and
scrutinized in multiple studies with consistently positive
reports (AANP, 2016).
The biggest barriers to practice for all groups have
been the limitations set in state statutes and regulations.
Of those, the requirements for formalized agreements
with physicians to prescribe or practice have created the
most frustrating barrier. This has been particularly true
for NPs and CNMs who, to practice and receive reimbursement, must find physicians who will agree to serve
as collaborators. CRNAs, particularly in rural areas, suffer
from similar problems.
Once a physician has agreed to serve as a consultant,
both the APRN and physician often find the reporting
rules to be frustratingly cumbersome. Although it now
occurs infrequently, requirements to list types of patients
that may be seen, consultation patterns to be maintained,
types of drugs to be prescribed, and identification of physicians to serve as backup in the absence of the identified
collaborating physician still sometimes plague APRNs.
Although, generally speaking, pharmacists have been
cooperative and NPs report a good working relationship
with pharmacists, issues such as continued use of the collaborating physician name as the prescriber on a medicine
bottle label and requests for the name of the supervising
physician before dispensing a prescription have frustrated
APRNs, physicians, and patients through the years. The
requirement of a Drug Enforcement Administration (DEA)
so without difficulty or negative repercussion. Overall,
the trend toward the removal of barriers to prescribing
has resulted in the removal of limitations of drugs to be
prescribed and the requirement for physician collaboration to do so. Although barriers in a few states still exist
in the authorization to prescribe controlled substances,
the limitations of authorization to prescribe legend drugs
have disappeared.
Advanced Practice NursePhysician
Relationships in Statute and Regulation
The requirement of some sort of collaborative arrangement with physicians to prescribe is often coupled with
the prescriptive authority patterns discussed previously.
Whereas many states do not require formal collaborative
arrangements with physicians, the remainder have some
requirement for collaborative or supervisory agreements
with physicians to practice or prescribe medication. For
NPs, approximately one-third of the state statutes and
regulations have no requirements, less than one-fourth
require supervision or have delegated authority, and
the remainder require some kind of collaborative or
consulting arrangement with a physician. These arrangements range from identifying a consulting physician
to submission of a written agreement to the regulatory
board(s) for filing or approval (AANP, 2016). CNMs
have a similar pattern: Approximately one-fourth have
no requirements, approximately one-fourth require a
supervising physician, and the remainder require some
kind of collaborative or consulting relationship in statute
or administrative rule (ACNM, 2016). CRNAs have
supervising or cooperating physicians in most states
(AANA, 2016), whereas CNSs, in the states in which
they have prescriptive authority, tend to have the same
requirements as NPs (NCSBN, 2016).
Some of these requirements stem from a desire on the
part of legislators or interested and influential parties for
physician oversight to prescribe; others have been driven
by reimbursement laws and policy that calls for physician oversight of APRNs. Sometimes rules are made for
APRNs that reflect the supervisory relationship required
of physician assistants (PAs) without considering the fact
that APRNs are accountable under their own license, carry
their own liability insurance, and in the majority of states
are not required to be supervised by physicians, as are PAs.

98 Unit 2 The Practice Environment
patterns reflected the specialty and the practice setting of
the NP. In these studies the mean number of prescriptions
per day for all NPs was approximately 19, with family, adult,
and emergency NPs among the highest daily prescribers.
Drugs most frequently prescribed by all specialties in
thesestudies were antimicrobials, anti-inflammatories, and
analgesics. Antihypertensives, bronchodilators, and cardiovascular drugs were prescribed most frequently by adult,
family, and gerontological NPs. Contraceptives were most
often prescribed by womens health NPs. The vast majority
of NPs practicing in emergency department settings prescribe analgesics, anti-inflammatories, and antimicrobials
most often, and in the Department of Veterans Affairs
(VA) hospital setting, the vast majority of NPs prescribe
antihypertensives and cardiovascular drugs most frequently,
followed by diabetic medications, gastrointestinal medications, and analgesics. Among NPs authorized to prescribe
controlled drugs, the majority of adult, family, gerontological,
and psychiatric and mental health NPs prescribe them at
least once a week with the highest percentages being in the
hospital and VA hospital setting.
CNM prescriptive activities center on medications
needed for prenatal care, such as vitamins, and intrapartum and postpartum care, such as analgesics. In addition,
their prescribing practices are similar to those of womens
health NPs. They include contraceptives and other hormone therapies, vaginal preparations, and antimicrobials,
as well as anti-inflammatories, analgesics, and vitamin
therapies (Towers, 1999a). The CNSs who most often
prescribe medications at this time are the psychiatric and
mental health specialists. In a study conducted by Talley
and Richens (2001), psychiatric and mental health CNSs
authorized to prescribe controlled drugs were reported
to most frequently prescribe antidepressants (selective
serotonin uptake inhibitors and tricyclic antidepressants).
The next most frequently prescribed medications were
antiparkinsonian drugs and antihistamines for neuroleptic
side effects and sleep, followed by mood stabilizers such
as lithium and carbamazepine.
Among CNSs of other specialties, prescribing activities
appear to function around already diagnosed conditions
and altering, adjusting, or refilling physician-prescribed
medications in stable patients. The lack of authorization
and the desire to maintain autonomy in nursing practice
led many CNSs to choose not to obtain authorization
in settings in which such authorization is attainable.
number by insurance companies to pay for prescriptions
is still problematic, particularly in the two states where
APRNs are not yet authorized to prescribe controlled
drugs. This problem lands on the pharmacists doorstep
when they cannot obtain reimbursement for dispensed
drugs from insurance companies without an accompanying
DEA number. Although this practice is a misuse of the
DEA number, which is to be used for the prescription of
controlled drugs only, it has become common practice for
insurance companies and pharmacies to use this number
as an identifier because of its uniformity for physician
identification throughout the country.
Mail-order pharmacies sometimes create barriers for
APRNs. Occasionally, patients cannot obtain prescriptions
from these entities without the name or signature of a
physician. Although this is no longer a problem with most
mail-order pharmacies, those with warehouses located in
states where laws for this form of dispensing require the
order of a physician still occasionally pose difficulties for
patients with prescriptions written by APRNs.
Confusion about the role and scope of practice of an
APRN through the grouping of NPs, CNMs, and PAs as
midlevel practitioners has created problems for APRNs.
It is often assumed that the required supervisory arrangements for PAs is the same for NPs and CNMs, so that
policies related to practice, including prescriptive authority
and ordering of medications for patients, are often based
on the statutes and rules governing PAs rather than the
APRNs. Because most regulation of PAs stems from a states
medical practice act, insurance companies, institutions,
accreditation entities, and pharmaceutical companies
sometimes assume that the PA administrative rules apply
to APRNs and do not seek information regarding APRNs
from a states nursing practice act and supporting regulations. Because APRNs are authorized to practice more
autonomously in most instances, this assumption, and the
actions taken based on it, create barriers for the APRN,
particularly in relation to prescribing controlled drugs.
The AANP has conducted several national surveys that
examined the prescribing patterns of NPs throughout the
United States (Goolsby, 2005, 2009;Towers, 1989, 1999a,
1999b). Those studies found that an NPs prescription

Chapter 6 Advanced Practice Nurses and Prescriptive Authority 99
Medicine (IOM) report, The Future of Nursing: Leading
Change, Advancing Health (2011), reinforces the need for
APRNs to be authorized to practice to the full extent of
their education and training. Both documents reflect the
culmination of the APRNs evolution to full prescriptive
authority that generally exists today.
Prescriptive authority is now generally recognized as an
integral part of advanced practice nursing. Although
totally unfettered authority by all APRNs has not yet been
achieved, the experience of prescribing medications for
patients under the care of these providers has been found
to be safe and beneficial. The arguments put forth to limit
their prescribing activities grow weaker with each advance
that APRNs make. The practicality, the enhancement of
quality of care, and the cost-effectiveness of the practice
of these groups has enhanced the logic and desirability
of giving prescriptive authority to APRNs nationwide.
The position of the NACNS is that CNS prescriptive
authority should be optional and that when prescribing
is to be undertaken, the CNS should meet the requirements of any other APRN (Lyon & Minarik, 2001;
NACNS, 2005).
Authorizing APRNs to prescribe medications is no longer
a controversial issue; however, obsolete statutes and regulations still need to be changed in some states to guarantee
the unencumbered ability for APRNs to prescribe needed
medications for all patients.Toward thisend, two important
documents have been developed that reinforce the authorization of APRNs to function at their full educational
scope, which includes unrestricted prescriptive authority
for APRNs. The APRN Consensus Model (2016),endorsed
by 46 states and 48 national nursing organizations, provides recommendations for the education and certification
of APRNs (NCSBN, 2016). Likewise, the Institute of

Credentialing and Clinical
Privileges for the Advanced
Practice Registered Nurse
Ann H. Cary and Mary C. Smolenski
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Describe the purpose of credentialing for providers, institutions, regulators, and
the public.
Evaluate the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (LACE).
Explain the federal and state regulatory impact on the processes of credentialing
and privileging required by institutional providers and payers.
Justify the direct relationship between the processes and documents required for
the APRN credentialing process and the decisions for scope of practice or clinical
privileges made by the employing institution.
Discuss the unique aspects of credentialing and privileging in telehealth and telemedicine as well as during disasters.
Justify the creation and maintenance of the APRN portfolio as a documentary
tool for use in credentialing.
Discuss challenges that the APRN may experience related to the changing nature
of institutional and regulatory requirements.

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 101
outcomes have a dramatic and common impact on the
APRNs ability to execute the full scope of practice and
thus has resulted in the AARP (formerly the American
Association of Retired Persons) issuing a warning: barriers
(to APRNs) . . . are short-changing consumers (IOM,
2011, p. 106).
For almost a decade there has been a plan and model to
remove barriers to APRN practice with the issuance of the
Campaign for APRN consensus: Model for uniform national
advanced practice registered nurse regulation (2008) and the
credentialing and privileging processes for providers issued
by CMS and The Joint Commission (TJC) (2012). The
Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (NCSBN, 2008)
or LACE promotes uniformity of national standards and
regulation by the states to promote mobility of APRNs
and access to APRN care. The APRN Regulatory Model
includes (OSullivan, 2011):
Licensure: The granting of authority to practice
Accreditation: Formal review and approval by a recognized agency of educational degree or certification
programs in nursing or nursing related programs
Certification: The formal recognition of knowledge,
skills, and experience demonstrated by the achievement
of standards identified by the profession
Education: The formal preparation of APRNs in graduate or postgraduate programs
Because credentialing verification includes the education,
certification, and licensure of the APRN and accreditation
of the educational institution from which the APRN graduated, the LACE model under consideration by the states
for uniform APRN preparation and credentialing, once
executed, can reduce APRN barriers to practice. Each state
board with jurisdiction over APRN education and practice
will need to adopt the LACE approach in order to foster a
standard approach to APRN education, certification, and
practice regulation. The impact of full implementation of
the LACE model will simplify the credentialing process
required by the APRN and the employer. Most of the
states have adopted some aspects of LACE but it is far
from fully implemented to date. The reader can access the
model and explanation at
To assure consistency of standards and processes for providers, both the CMS andTJC have undergoneregulatory
changes related to the issuance of uniform processes and
Credentialing and privileging of health-care providers, and
advanced practiceregistered nurses (APRNs) in particular, is
theinitial and ongoing mechanism employed by regulatory and
voluntary oversight and delivery systems to ensure protection
of the public and quality patient care during the delivery
of health-careservices. According to the U.S. Department
of Health and Human Services (DHHS) credentialing is
the process of assessing and confirming the qualifications
of a licensed or certified health care practitioner (HRSA,
2001, 2006). The independence and autonomy of APRN
services necessitates the same degree of attention to the
processes of credentialing and privileging as accorded to
physicians and other providers. The process is a critical
dimension of any risk management plan and is reflected
in the level of responsibility assumed by the governing
board, medical staff organization, or top administrator
of the institution. APRNs are increasingly being granted
privileges in acute care and hospicesettings and participate
in provider networks as primary care practitioners. In some
states APRNs are eligible to bill as primary care providers
(Center for Advancing Provider Practices, 2016).
Credentialing certification of providers, verifying provider credentials, establishing privileges, and accrediting
institutions serve five purposes (adapted from Cary, 2015):
1. Public protection
2. Quality assurance and risk management
3. Consumer information and choice
4. Competitive advantage
5. Economic advantage
The Institute of Medicines (2011) Future of Nursing:
Leading Change, Advancing Health has challenged nursing
and society to allow nurses to practice to the full extent
of their education and training (p. 4). Recommendation
#1 asserts that in order to master this challenge, barriers to
the scope of practice as detected by actions in Congress,
state legislatures, the Centers for Medicare and Medicaid
Services (CMS), the Federal Trade Commission (FTC),
and the Department of Justice (DOJ) must be removed.
In addition, organizational barriers of the APRN employer
may be equally oppressive to those at the macro level.
APRNs who experience these barriers often encounter
them during the process of credentialing and as an outcome
of the privileging process. Credentialing and privileging

102 Unit 2 The Practice Environment
allowances for the credentialing and privileging of medical
and allied health professionals (including APRNs and
physician assistants [PAs]). Although an institution can be
more restrictive in privileging it cannot be less restrictive
than the CMS Conditions of Participation (CoP). Because
CMS no longer recognizes an equivalent process for credentialing and privileging of certain providers who provide
medical level of care, APRNs providing this level of care
must now be processed through the medical staff standards
process at the institution or system (Cheung, 2011). This
process includes recommendations of the medical staff,
approval of the governing body, and implementation of
review performance processes such as the initial focused
professional practice evaluation (FPPE) and ongoing professional practiceevaluation (OPPE). If the APRN does not
provide medical level of care, the APRN can be processed
through an equivalent process (Cheung, 2011).
This chapter discusses credentialing and privileging as
separate mechanisms with the understanding that analysis
of the data about the APRNs application process of credentialing is a precursor to the decision about the nature
of activities (specific procedures or treatment of specific
conditions) for which privileging will be awarded (Pelletier,
2015). Issues related to credentialing and privileging for
APRNs within the health-care arena are also presented. The
reader is advised to maintain access to new developments
in these areas because barriers to executing full scope of
practicefor APRNs appear to be rapidly changing in federal
and state regulations, as well as voluntary, employer, and
provider groups.
The preludeto any discussion on credentialing is grounded
in the fact that the graduating APRN today must have
an earned graduate degree or postgraduate coursework
in the additional area of focus once a graduate degree is
conferred. The institution conferring the degree must be
accredited by a regional accreditor of higher education
and, in most cases, a nursing accrediting organization
recognized by the U.S. Department of Education. Once a
student graduates and meets alleducational requirements
masters, post-masters, or doctoral programfor
preparing the APRN graduate, the student must achieve
a passing score on the certification examination.
Certification confers the initial, specific voluntary
credential for the APRN. There is yet to be uniformity
among the states as to whether an additional regulatory
(nonvoluntary) credential process is required to practice
in a particular state based on the certification credential,
such as obtaining a second state license as an APRN. The
value of the LACE model described earlier is to regulate
uniformly among the states how nurses and educational
institutions are credentialed based on a national standard
and how these are recognized as equivalent among the
states. However, the LACE model in total has not yet
been adopted by the majority of the states. Renewal of
APRN certification, for all except the certified registered
nurse anesthetist (CRNA), is conferred by a combination
of practice hours, continuing education, and academic
coursework in accordance with the requirements of the
respective (re)certifying organization.
The new model, structure, and process of recertification for CRNAs was initiated August 1, 2016, by
the National Board of Certification and Recertification
for Nurse Anesthetists (NBCRNA): the Continued
Professional Certification program (CPC). This shift in
recertification was driven by the expectation of consumers
for the measurement of continuing competency in the
recertification of health-care providers and may well
portend a shift in the recertification process of all APRNs
in the future. One difference in the recertification of the
CRNA relates to the addition of an examination to the
process of the recertification cycle. To obtain the most
current information about the recertification process
and the phased timeline for the CRNA certification and
recertification access
(Box 7.1).
Credentialing involves the collection, verification, and
assessment of information determining the eligibility and
qualifications of the APRN provider to provide health-care
services and includes three categories: current licensure
and certification; education and training; and experience,
ability, and current competence to perform the work (TJC,
2008). Whereas privileging decisions are based on theinitial
and ongoing evaluation of the applicants credentials and
performance competencies, the credentialing process itself
guarantees the integrity of the data issued for the APRN
and serves as the basis of decisions regarding privileging
authorization for scope of practice and appointment of
the APRN in a facility or system.

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 103
application process. Organizations may use a two-step
process for credentialing: preapplication and application.
A preapplication typically will address any disciplinary
actions or sanctions by regulatory or professional organizations; current unrestricted license; criminal history;
board certification; clinical specialty requirements; and
health status information compliant with the American
Disabilities Act (MedPro, 2014).
A written application must be submitted to the
authorized department or person in an institution.
The application may be lengthy, and completeness and
accuracy of information are critical to ensure timeliness
of processing. Review of the application examines both
the submission of information by the APRN and source
verification as well as consistency of information among
all sources. Any gaps in information or inconsistency are
further investigated by the institution before a decision
is made for appointment. The APRN is responsible for
adding information as needed and answering queries
for incomplete or inconsistent data. In circumstances
The types of data gathered during the credentialing
process are directed by federal and state regulations; professional standards; facility requirements, policies, and
procedures; and voluntary oversight bodies. Medicare CoP
guidefederal and many state-regulated processes; standards
of practice guide the professional standards; institutional
bylaws, policies, and procedures mandate the specific
application of the credentialing and privileging processes
for the employed, independent contractor or a licensed
independent practitioner (LIP)an APRN can be a LIP;
and voluntary or semiregulatory accreditation standards
mandate the institutional processes. At a minimum,TJC
standards require credentialing and privileging of all LIPs
and APRNs who deliver a medical level of care permitted
by law and the organizational bylaws to provide patient
care without supervision or direction (Pelletier, 2015).
Regardless of the particulars of data required to support
the APRN application, there are common data elements
that the APRN can expect to see on the application.
Credentialing Application and Procurement
of Data: Preapplication and Application
Data that are required to support the application for
APRN appointment or reappointment to a clinical
position fall into several general categories. Box 7.2 lists
the common categories included in the credentialing
Personal and practice demographic information
Education and training
Clinical performance
Work history
State(s) licensure history (including state-controlled
substance licenses)
Drug Enforcement Agency (DEA) certificates
Provider number or ID
Criminal background report
Liability insurance and claims history
History of sanctions and penalties imposed on
practice and voluntary relinquishment of licenses
and certifications
Disclosures of physical, mental, substance, or
criminal problems
Attestation of information completeness and accuracy
Authorizing statement to collect any information
necessary to verify application
Box 7.2
Categories of Data Required to Be Satisfied
for Credentialing Application
American Academy of Nurse Practitioners Certification Programs (AANPCP)
American Association of Critical-Care Nurses
Certification Corporation (AACNCERTcorp)
American Midwifery Certification Board (AMCB)
American Nurses Credentialing Center (ANCC)
National Board of Certification & Recertification
for Nurse Anesthetists (NBCRNA)
National Certification Corporation (NCC)
Pediatric Nursing Certification Board (PNCB)
The American Board of Comprehensive Care(ABCC)*
Box 7.1
Organizations Offering Certification
and Recertification for APRNs
*This organization is not recognized or used for regulation.

104 Unit 2 The Practice Environment
with credentialing verification organizations (CVOs) to
collect the primary and secondary data on which the
decision for appointment will be made. For example,
CAQH has more than 1.3 million physicians and other
health-care professionals engaged in CAQH ProView, an
online Universal Provider Datasource (UPD) that allows
providers to self-report updates in credentials to a database
that can be accessed by employers (CAQH, 2016). The
institution contracting with any CVO is responsible for
monitoring the quality of service provided by the CVO
and may require the CVO to be accredited by one of the
national accrediting bodies such as URAC. The institution
is not relieved of liability resulting from decisions based on
contracted CVO data and processes for credentialing of
APRNs. In addition, the institution remains accountable
for the accreditation standards issued by its accreditation
bodies such as TJC.
Analysis of Credentialing Application
Upon completion of the APRN application review and
verification processes, the final step is institutional decision
on appointment. This is guided by institutional policies
and procedures related to structure of the decision-making
body; roles of the members; risk management and legal
reviews; due process mechanisms; documentation requirements for decisions; and reporting mechanisms to
the institutional board of directors, clinical directors, and
the applicant. In some institutions, the human resource
department processes the data for credentialing, whereas
in other institutions certain providers are credentialed
by the medical staff. An organizational model at the
University of Rochester, The Margaret D. Sovie Center
for Advanced Practice, serves as a centralized coordination
center for the core APRN functions related to regulation,
institutional requirements, and credentialing with a direct
line to the medical staff office. The center also functions
as a repository for credentialing information, state licensure, prescriptive authority, and DEA numbers. See more
information on the Sovie Center at www.urmc.rochester
In most institutions, the credentialing committee is
composed of physicians. As more APRNs become credentialed, their representation on medical staff committees
will need to be embraced and the bylaws adjusted to
expand governance for APRNs as part of provider panels
where changes in status occur (e.g., licensure renewal,
registration, additional education and certifications,
recertification, voluntary or involuntary termination of
staff membership, reduction or loss of privileges), the
provider is obligated to submit the respective information to the credentialing body immediately for review
of appointment status. Falsification of information or
intentional omission of information on the application
may be grounds for termination of the process, disciplinary action, or dismissal. If credentialing is denied,
this is typically reported to the National Practitioner Data
Bank (NPDB) (Pelletier, 2015). For APRNs working in
managed care organizations (MCOs) credentialing for
most health plans is largely conducted by a vendor such
as the Council for Affordable Quality Healthcare, Inc.
(CAQH) (Buppert, 2015).
Verification of Advanced Practice
Nurse Application Data
Two types of verification of data sources, primary and
secondary, are conducted on an application in accordance
with the rules and regulations of the accountable body
for credentialing within the institution and as directed
by the institutional accreditation process. Primary source
verification attests to the accuracy and authenticity of the
APRNs credentials based on evidence obtained from any
source issuing the credential or the attestation of clinical
performance. Examples include verification of licensure by
state agency and certifications by certifying bodies, letters
by authorized personnel at the professional school, letters
from individuals personally acquainted with the APRNs
skills, and database queries. Secondary source verification
relies on verification actions of the APRN credentials based
on data obtained by means other than direct contact with
the issuing source of the credential (Utilization Review
Accreditation Commission [URAC] 2011, 2016). Examples include unofficial copies of documents or reports on
patient satisfaction statistics by the applicant. It can also
include peer references or quality data information from
past employer organizations.
Some credentialing processes allow for documentation
secured by Internet or telephone verification. State nursing
licensure boards are continuing to evolve technologically
and many have online license verification processes such as
Nursys. In addition, some health-care institutions contract

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 105
Organizational Standards for Credentialing
Advance Practice Nurses in Institutions
APRN practices can be found in almost all venues of
health-care delivery. Appointment and privileging oversight mandates from credentialing organizations have
broadened the standards to include LIPs in hospitals,
ambulatory care organizations, subacute long-term care,
hospice, mental health, and MCOs, regardless of practice
structures. Credentialing for other delivery systems is on the
horizon. Because the standards of sponsoring organizations
can change annually, the reader is advised to consult the
many Web sites related to these topics to obtain the most
current information possible on standards for accreditation as they relate to credentialing and privileging of the
APRNs practice.
Once the application for credentialing is approved, a
subsequent decision is made by the institution to authorize
the specific practice activities (privileges) of the APRN.
In some instances a separate privileging application is required. Consult institutional policies for their procedures.
Once a process that hospitals used to award physicians the
right to admit and perform clinical activities within their
facility, privileging is now a process faced by many APRNs as
they apply for positions within health-carefacilities, MCOs,
mental health and substance abusetreatment facilities, and
even doctors offices (if the APRN will befollowing private
patients in the acute-care setting). Privileging is used by a
facility or employing organization to authorize a providers
specific scope of patient careservices that are consistent with
an evaluation of the providers clinical qualifications and
performance for specific diagnostic or therapeutic services
within well-defined limits.The granting of privileges is based
on thefollowing factors: state practice acts, agency regulations,
licensure,education, training,experience, competence, health
status, and judgment. It should be noted that just because
the state practice act authorizes a particular activity (e.g.,
prescribing narcotics), a particular institution may be more
restrictive and may not allow this privilege or may require a
secondary signature by a physician. Monarch (2002) identifies
seven categories of staff privileges within health-carefacilities
and systems. These are shown in Box 7.3.
and teams. The credentialing process is time consuming
because of the importance of adhering to principles of
good data integrity and decision making. It can often
take 90 to 120 days (Monarch, 2002). It behooves the
APRN to obtain a copy of the policy and procedures for
the credentialing process, committee member list, schedule of meetings, anticipated action on the application,
and due process mechanisms. Rapid responses to queries
facilitate the completion of data collection and decision
making. Also, alerting primary sources of the impending
request by the verification body can facilitate the response
for information.
When a credentialing process results in an appointment
to the staff, the length of appointment and reappointment procedures are guided by institutional policy. It
is wise to obtain copies of the reappointment process
and criteria and continuously compile the necessary
evidence to meet the criteria for reappointment. As
new technologies and procedures become common,
the APRN needs to understand the minimum criteria
for credentialing in new procedures and document
accordingly (TJC, 2008).
Decisions for emergency credentialing of volunteer
LIPs have been revisited since 2002 because of national
and local emergencies. For example in 2002,TJC created
a standard that allows the institutional chief executive officer, medical staff president, or his or her designee to grant
emergency privileges when an emergency management
plan has been activated. Implications for credentialing
focus on data integrity: acceptablesources of identification,
including a current license to practice, current hospital
identification with the license number, or verification of
identity by a current hospital or medical staff member
(TJC, 2012). Joint Commission Emergency Management
(EM) standards for providers include:
EM.02.02.13 During disasters, the hospital may grant
disaster privileges to volunteer licensed independent
EM.02.02.15 During disasters, the hospital may assign
disaster responsibilities to volunteer practitioners who
are not licensed independent practitioners but who
are required by law and regulation to have a license,
certification or registration.
Time limitations are always imposed for credentialing
providers in this status.

106 Unit 2 The Practice Environment
permissive language that allowed hospitals to include
other licensed individuals (permitted by law and by the
hospital) to provide patient care services independently in
the hospital. These privileges usually include clinical and
admitting practices. TJC also established a mechanism
to monitor these privileges and charged the hospital to
establish criteria for clinical privileging and a process to
ensure that competent individuals are providing patient
care. Some facilities may have a list of core privileges
that are appropriate for a particular type of provider or
specialty practice. For example, HCPro provides sample
core privilege forms that facilities can use for APRNs
in dermatology and emergency rooms, acute care nurse
practitioners (NPs), clinical nurse specialists (CNSs) in
psychiatric mental health, and for CNMs (HCPro, 2016b).
TJC is not prescriptive as to what process should be used
for privileging nor do they endorse or devalue the use of
laundry lists or core privileges. However, TJC requires
evidence that the facility does indeed evaluate whether the
individuals are qualified and competent to perform the
privileges they are granted by the process (TJC, 2012).
The standards of TJC speak to the issue of hospital
privileging in the sections on Leadership (LD) and Medical Staff (MS). The standards speak to the process itself
and to the mechanisms that must be in place, executed,
and outlined in the hospital bylaws. These processes must
include the time frames, the appeals processes, criteria for
appointment and determining specific privileges, those
responsible for the credentialing and privileging process,
the reappointment process, temporary privileging, telemedicine privileges, disaster privileges, and the quality
improvement process. Those who provide medical level
of care must use the medical staff process for credentialing and privileging, making all [medical staff] standards
applicable (including recommendation by the organized
medical staff and approval by the governing body, OPPE,
and FPPE). APRNs and PAs who provide medical level
of care must be credentialed and privileged through the
medical staff standards process. APRNs and PAs who
do not provide medical level of care utilize the human
resources equivalent process detailed in HR.01.02.05,
EPs 10-15 (TJC, 2012).
One area of credentialing and privileging approved by
the CMS concerns the approval of TJCs requirements
for telemedicine practitioners in hospitals and critical
access hospitals as published in the 2012 Update 1 to the
Rationale and Background
Privileging is a component of the credentialing process of
health-care facilities. As mentioned previously, national
accrediting bodies such as URAC, the National Committee
for Quality Assurance, TJC, and the Accreditation Association for Ambulatory Care establish both the credentialing and privileging standards and processes by which
organizations are accredited. In the early 1980sTJC (then
the Joint Commission on the Accreditation of Healthcare
Organizations [JCAHO]) revised its definition of medical
staff and broadened the scope of practice rules to include
Activeallows the health-care provider to admit
patients and participatein other hospital programs.
Courtesyawarded when a limited number of patients
will be admitted and when the health-care provider
is an active member of another medical staff.
Affiliateawarded when the health-care provider
is no longer active, but has a longstanding relationship with the hospital.
Outpatientawarded when the health-care provider
is regularly engaged in the care of patients in
outpatient settings or in programs sponsored
by or on behalf of the health-care organization.
Honoraryawarded when the health-care provider is no longer active, but has outstanding
accomplishments or reputation. Honorary staff
privileges are distinguished from affiliate staff
privileges in that honorary staff privileges permit
the health-care professional to continue to admit
patients to the organization.
Houseallows a health-care professional to admit
patients within a specialty area with the approval
of an active staff member.
Allied Health Professionalpermits nonphysician
health-care providers to provide specified patient
care services.
Box 7.3
Staff Privileges Categories
Reprinted with permission from Monarch, K. (2002). Nursing and the law:
Trends and issues. Washington, DC: American Nurses Association, p. 246.
2002 By American Nurses Association. Reprinted with permission. All
rights reserved.

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 107
and privileging file, two other processes also allow for
closer evaluation. The first is a FPPE. As specified in TJC
Standard MS.08 the FPPE is implemented for all initially
requested privileges using performance criteria to judge
competency. It can be subsequently used via a performance
monitoring process when patient safety issues concerning
competency, behavior, and ability to perform are documented. The second process is the OPPE; it supports
an evidence-based approach to maintain credentialing
and any decision to maintain, revise, or revoke existing
privileges. Hospitals use a variety of approaches to assess
APRN competency including physician review, peer review,
focused case review, direct observation, coworker review,
charts and documentation, and simulation testing (Center for Advancing Provider Practices, 2016). APRNs are
subject to the credentialing, privileging, and monitoring
processes, as are physicians, in accordance with applicable
bylaws, rules, and regulations using the providers scope
of license and related standards.
When the process is done correctly, credentialing and
privileging provide protection for the facility, the patient,
and the practitioner. The process attempts to decrease
risk for the facility and the practitioner by ensuring that
the practitioners providing care to patients are currently
licensed, have been educated for the role in which they are
working, and are safe and competent in the scope of care
they are authorized to provide. The intent is that patients
ultimately benefit from well-educated, safe, competent
practitioners. The process in an accredited organization
also provides some security for the practitioner because
federal law regarding participation in Medicare requires
that staff membership and professional privileges in a hospital are not dependent solely on certification, fellowship,
or membership in a specialty body or society (42 C.F.R.
482.12 (a)7) (Buppert, 2015).TJC also spells out that an
appeals process must be in place if privileges are denied.
The process provides for time frames and feedback to the
practitioner and provides mechanisms for temporary or
emergency privileging. Finally, privileging provides data
for determining the economic effect of provider practice
on the health-care system.
As stated in the definition, there areseveral factors that
affect the outcome of privileging: state practice acts, agency
regulations, license,education, training,experience, competence, health status, judgment, the culture of the medical
staff, and the medical staffs bylaws. Thefactor that affects
Comprehensive Accreditation Manual for Hospitals and the
Comprehensive Accreditation Manual for Critical Access Hospitals. These new standards appear as Standard LD.04.03.09
and MS.13.01.01 (The Joint Commission Perspectives,
2012). Several areas bear attention (TheJoint Commission
Perspectives, 2012): The originating site(wherethe patient
is located) must have a written agreement with the distant
site(wherethe provider is located) assuring compliance with
Medicare CoP related to credentialing and privileging of
providers. The governing body of the originating site grants
privileges to a distant site independent practitioner based
on the originating sites medical staff recommendations,
which rely on documentation provided from the distant site
if that site is a Joint Commission-accredited organization.
The distant site practitioner must hold an activelicensethat
is issued and recognized by the state in which the patient
is receiving the telemedicine services. The originating
site collects evidence of internal review of a practitioners
performance of the privileges and sends this information
to the distant site to assess quality of care, treatment, and
services. Such information includes documented adverse
outcomes related to sentinel events as well as complaints
by patients, providers, and staff at the originating site.
In the case of a disaster, an APRN may be granted
disaster privileges through a modified process. This process
is typically granted for two conditions: when a disaster
management plan has been activated and when the organization is unable to meet immediate patient care needs.
At a minimum, verification of license and oversight of care
treatment and services must be provided (TJC, 2016).
Continuing education is also mandated in TJC standards, as are four core criteria: current licensure, relevant
training or experience, current competence, and ability
to perform privileges requested.
Six areas of competence inform the evaluation of a
practitioner in TJC standards for the credentialing and
privileging process. These are:
1. Patient care
2. Medical and clinical knowledge
3. Practice-based learning and improvement
4. Interpersonal and communication skills
5. Professionalism
6. System-based practice
In addition to incorporating the aforementioned concepts
into the overall evaluation of an individuals credentialing

108 Unit 2 The Practice Environment
outline safe practice. Delineation of the specific types of
privileges may be presented in a variety of ways, and each
facility may have its own guide of core privileges. Among
the basic types of approaches are the following: category,
laundry list, severity or complexity of care, and hybrid
form. The first, category, usually defines privileges along
specialty lines and can vary significantly across types of
specialty programs because of curriculum. The listing
of privileges and skills, or the laundry list approach, is
used mainly for procedures and is less appropriate when
specific diseases are referenced because of the variability
of presentation. For example, some of the specific tasks or
procedures identified by Kleinpell and colleagues (2008)
in a sample privilege request form for which an acute
care NP might want to obtain hospital privileges include
ventilator adjustments, managing resuscitation, digital
block, chest tube insertion, and insertion of arterial or
central venous catheters. The severity or complexity of care
is the third form, and the fourth is a variation or hybrid
of those previously mentioned.
The credentialing panel or peer review panel who reviews
the credentialing files may also determine the applicants
privileges, or there may be a separate panel composed of
members, including peers, from the particular service or
area. Theideal panel includes an interdisciplinary group with
APRNs represented. This group determines if a candidate
applying for particular privileges meets the criteria based
on the information submitted in his or her credentialing
package and application. They may allow the practitioner
independent privileges or supervised privileges depending
on theevaluation. Other strategies that providesupport for
the credentialing and privileging of APRNs besides representation on the credentialing panel includerepresentation
in the development of any policies and procedures relevant
to the process and communication networks for periodic
updates on changes or alterations in APRN credentialing
and privileging practices (Kleinpell et al, 2008).
Accreditation requires that the privileges and credentials
files be reviewed every 2 years at a minimum to ensure
currency and competence. However, clinical privileges
are reviewed, revised, or updated for a variety of reasons
other than at the time of reappointment. Evaluations of
performance may warrant privileges being expanded or
reduced. Nonuse of privileges may indicate that specific
privileges are not needed and competency cannot be
maintained. Finally, as technology and innovation emerge
APRNs most is the scope of practice outlined in the state
practice act for thestate of licensure and authorization. Each
state continues to regulatethe practice of APRNs differently
at this time(although it may dramatically change with full
implementation of the Consensus Model), and the scope
of practice outlined in state regulations or statutes can be
broad or narrow. Some practice acts define what APRNs
can do and what specific drugs they may or may not prescribe, if they have prescriptive authority. The health-care
agency regulations for credentialing and privileging are
usually defined by the medical staff and hospital board and
may restrict APRNs from performing certain procedures.
The license and authority to practice as an APRN is tied
to scope of practice issues outlined in each state practice
act. Education provides the theoretical and experiential
components to develop specific outcome competencies
(as determined by the professional organization and the
profession in scope and standards of practice). Forexample,
the outcome competencies for a pediatric NP would not
bethesame as thosefor a geriatric NP, although there may
be some overlapping competencies.
It is important to document education, training, and
experience as practitioners progress in their careers because
not everything essential for practice can be learned in the
formal education process. A portfolio approach is essential
to establish and maintain. However, just because a practitioner learned a particular procedure does not mean he or
she is legally allowed to perform it because the procedure
may be outside the scope of practice and license. Health
requirements (both physical and mental) are evaluated
and certain restrictions may apply. Untreated substance
abuse problems and physical impairments may interfere
with the performance of a particular role. Competence and
judgment become a little more subjective when evaluating
and reviewing a privileging file. Many of the components of
the provider file are taken into consideration when making
an overall determination of competence and judgment,
and the credentialing panel may want to establish a period
of observation and performance evaluation.
Therapeutic and diagnostic patient care services that fall
under the privileging framework are usually defined by
the particular medical or surgical specialty area within
the health-care facility, and criteria are established that

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 109
certifying bodies, and educational institutions. Hospitals
use them for evaluation and career ladder programs.
Regulatory agencies use them for assuring the public
that practitioners are competent, such as in Ontario,
Canada. Dietitians use them for their recertification
processes. Certifying bodies use them for recertification
or reactivation of credentials. Educational institutions
use them for advanced placement of RNs into bachelors
of science and graduate programs and for compiling
clinical practice evidence for doctoral projects. Professional career portfolios serve as the foundation of the
credentialing and privileging application process used
in todays health-care system.
Evidence-based practice provides a scientific, justifiable rationale for patient care therapeutics, whereas
practice-based evidence provides a rationalefor authorizing
a practitioner to perform specific patient care therapeutics.
Documentation of this practice-based evidence provides
the information needed for making decisions regarding
the privileging component of the credentialing process as
currently outlined.
Tracking the events in our own lives becomes more
and more complex, even though one would think it
should be easier with all the technology available. As
we add new experiences and roles to enrich our professional careers, work with new practitioners in a variety
of settings, learn new skills, and pursue a path of lifelong learning, it becomes more and more imperative
to document where and when we did what, and where
and when we learned what from whom. Establishing a
professional credentialing portfolio as the APRN begins
his or her advanced practice education and career can
make the credentialing and privileging process easier
and save time and money. It may even assist the APRN
to be more adequately compensated by allowing him or
her to achieve a higher status within a health-care facility
because of practice-based evidence. The credentialing
and privileging portfolio described here can build on
this process. For students or early professionals building
a portfolio, Beauchesne (2007) suggests including some
of the following items (pp. 3435):
Personal statements on practice and scholarship
Case studies and research activities
Health-care project descriptions
across hospital procedures and in the treatment of various
diseases, the scope of privileges also change. Privileging
is an ongoing process; new privileges may be added and
some may be removed based on performance.
Temporary privileging may need to occur from time to
time when a particular provider becomes ill or disabled,
necessitating that another provider be recognized to take
over certain duties of care. Recently recruited providers
whose skills are specialized and needed in the facility
may be awarded temporary privileges while the formal
process of credentialing continues. These privileges are
time limited and primary source verification of licensure
and competence are allowed through phone calls until the
full credentialing process occurs.
The NPDB serves an important role in the credentialing process. The NPDB Public Use Data File contains
selected variables from medical malpractice payment and
adverse licensure, clinical privileges, professional society
membership, and Drug Enforcement Administration (DEA)
reports (adverse actions) concerning physicians, dentists,
and other licensed health care practitioners and updated
four times annually. It also includes reports of Medicare
and Medicaid exclusion actions taken by the Department of
HHS Office of Inspector General (HRSA, NPDB, 2014).
In a survey of NPDB users, Waters, Warnecke, Parsons,
Almagor, and Budetti (2006) found that many institutions use this inquiry process to make decisions about
credentialing and subsequently privileging in a timely
manner. Fewer than 10% of institutions indicated they
had reached a credentialing decision before receiving the
NPDB report, whereas up to 30% of respondents receiving
a NPDB report did not grant privileging applications as
requested. However, the issue of incidents not being reported to the NPDB still remains a barrier to the NPDB
process as a leverage to comprehensive access to provider
performance. Clearly multiple methods of data access and
analysis are needed to achieve the goals of any credentialing
and privileging system and the use of the NPDB is an
essential component of data on credentialing of APRNs.
The Professional Career Portfolio
Portfolios continue to play a role in the world of competence assessment. Portfolios are used in a variety of
ways by facilities, regulators, nursing organizations,

110 Unit 2 The Practice Environment
components are similar across portfolio types, some things
are unique to the credentialing and privileging portfolio.
Keeping the idea of credentialing and privileging in
mind, the following format is suggested for developing
this professional career portfolio. The professional career
portfolio is composed of four major components: (1) the
practitioner contact information page, (2) the practice-based
evidence component used to assist in determining specific
privileges, (3) the credentials component section, and
(4) the attestation page.
Practitioner Contact Information
An introductory page with the practitioners name, address,
contact information, identity, and photo (if desired) is
Practice-Based Evidence Component
This area provides evidence to support the six areas of
general competencies being evaluated during the hospital
credentialing process and includes aspects of patient care,
medical and clinical knowledge, practice-based learning
and improvement, interpersonal and communication skills,
professionalism, and system-based practice.The practice-based
evidence component should include the following:
1. Copy of thestate practice act governing scope of practice
in the state of licensure
2. Core competencies for the APRN specialty
3. A sampling of references on the cost effectiveness
and quality of care provided by APRNs
4. Copies of all job descriptions, especially where
clinical privileges were awarded
5. Specialty procedures or processes learned and verified:
a. in the educational process
b. on the job
c. through continuing education
(See the sample of verification form, Figure 7.1, which
could be used to validate these procedures.)
6. Letters of support and verification of practice competence in the areas outlined; include both peers and
supervisors or employers
7. Employment history, identifying significant
Brief papers and assignments
Publications and presentations
Evidence-based examples
Clinical practice logs or reflections
Video clips
Certificates of participation
Letters of support and recommendation
Continuing education activities
Evaluations and competency reviews
Course syllabi and transcripts
An online portfolio is an excellent way to build a professional career history that can serve multiple purposes,
including the credentialing and privileging process. The
CAQH UPD ( provides one example
of a provider database, CAQH ProView, that can help
health-care organizations and providers maintain accurate provider information. Registering with a database
such as UPD is free for providers. Licenses, certificates,
transcripts, and documents can be scanned or uploaded to the online portfolio, eliminating the need for
paper copies. Although some of the materials collected
during the student educational process (course syllabi,
clinical logs, reflections) may not seem pertinent for
the professional career portfolio, it is easy to archive
these data through an online portfolio, making them
available at a later time only if necessary. It is better to
collect more information and not use it than to need it
and not have it. Individuals can access their files anytime, anywhere with Internet access. Fear of misplacing
documents or having them destroyed by unforeseen
natural disasters (i.e., floods, hurricanes, or fires) can
be eliminated. Stronger security of online materials has
resulted from files that can be password protected. In
addition, a compilation of particular documents can be
sent to credentialing committees via e-mail or they may
be provided Internet access to them. Updates can be
added to the portfolio as new knowledge and skills are
acquired, making the portfolio a living document. For
those who are Internet-phobic, the same documents
can be stored on a flash drive, carried place to place, and
updated when needed. Just be sure to purchase a flash
drive with enough memory to store all current data and
have room to spare for updates.
The purpose for which a portfolio is used determines
the elements it should contain. Although many of the

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 111
Provider Name:
License Number and Certification:
Date(s) of performance
Procedure(s) or activity:
I, the undersigned, have observed and can verify that
he/she can safely perform the above outlined procedure(s)
independently/with supervision (circle one).
Phone: Date:
Figure 7.1 Sample verification of practice form.

112 Unit 2 The Practice Environment
and able to perform the clinical privileges I am
requesting. I permit the employer or gaining party
of this portfolio to verify any of the information
provided if necessary.
Although APRNs are joining the staff of various facilities in greater numbers, there remain several areas that
continue to challenge the APRN full scope of practice
and the process to achieve it in clinical settings. The
issues presented here are not exclusive, but provide a
springboard for fuller discussion and solution generation in a manner in which APN scope of practice can
benefit consumers.
Maintaining Data on Clinical
and Administrative Performance
APRNs are held to standards of performance that include
clinical practice and administrative standards. Both have
economic implications for decisions to appoint or reappoint
APRNs to an institutional staff. Theinstitution may find that
clinical performance falls outside established benchmarks
if patients under the APRNs care have excessive lengths of
stay, repeated and lengthy delays in appointments, quality
of care issues, and additional exposure to liability resulting
from variation in performance. Patient satisfaction may be
easily tied to performance. Institutions will need to more
closely track coding practices of APRNs in order to capture
the actual practice of APRNs and subsequent outcomes.
Without this data and analysis, performance cannot be
understood or managed in ways comparable with other
APRNs are wise to monitor their performance
against the targets of the organization and colleagues
and use the feedback to initiate personal or systems-wide
performance improvement strategies. Maintaining documentation of outputs and accomplishments, patient
acknowledgments, and cost savings are important assets
for the APRNs portfolio. It is also important that APRNs
8. Any performance outcome data that may have been
collected at places of employment (e.g., number of
patients seen per day, revenue generated, patient
9. Copy of the Consensus Document
Credentials Component
The credentials component should include the following:
1. Education (transcripts and diplomas)
2. Military history (if any)
3. Licenses (numbers and expiration dates or copies)
4. Certification(s) (national rolespecialty and subspecialty,
if applicable)
5. Additional certification(s) (e.g., advanced cardiac life
support, basic cardiac life support, pediatric advanced
life support, trauma nurse coordinator)
6. DEA and Medicaid numbers
7. National Provider Identifier (NPI) number
8. Insurance coverage and any liability history
9. Immunizations and dates
10. Languages spoken, written, and understood (identify
beginning, average, or advanced levels)
11. Research in progress or completed
12. Publications
13. Continuing education (no more than 5 years worth
or length of certification)
14. Professional organization membership and offices
held in those organizations
15. References (professional and personal)
16. Certified Background Report results
17. Any previous denials of hospital credentialing or
Attestation Page
The final page, or the fourth component, should include a
statement that is signed and dated by the provider attesting
to the information contained in the portfolio. This should
be updated every 2 years or more often as any changes
occur, as should the entire portfolio.
I,_____________________, attest to the
authenticity of the information contained in this
portfolio and verify that I am in good health

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 113
Managed Care Panels
Health-care providers work in a competitive environment where more than one type of provider may be able
to provide the same scope of practice or provide partial
activities within another scope of practice. The ability
to be credentialed and apply for legal scope of practice
privileges rests in the hands of the credentialing structure.
Professional medical societies are flush with complaints
from physicians who perceive they have been excluded
from MCO provider panels, and these exclusions present
a glass ceiling for APRNs as well.
Sometimes the exclusion of APRNs is because of
lack of knowledge concerning the full scope of APRN
practice parameters; at other times there is a perception
of anticompetitiveness or restraint of trade action (IOM,
2011). APRNs are well advised to provide documentation
about APRN performance outcomes compared with other
providers through the use of evidence-based reports and
articles and quality reports, especially ones published in
the providers representative journals. Seeking advocates
and allies at the institution to which the APRN is applying
can assist in the politics of selection for worthy candidates.
Where warranted, legal consultation may prove helpful to
understand the issues and the APRNs rights.
Another issue intertwined with managed care panels
is reimbursement. Medicaid managed care in particular
becomes tricky when (a) state laws affect recognition of
NPs as PCPs, (b) federal Medicaid law permits pediatric
and family NPs to be used in primary care management
but does not require it, and (c) the law is silent regarding
the inclusion of these providers in Medicaid managed
care provider panels. Whether NPs, who serve more
than half of all Medicaid beneficiaries, can be designated
PCPs in MCOs is dependent on states policy choices
and individual MCO credentialing policies (Van Vleet &
Paradise, 2015).
Credentialing of the APRN
Across Multiple Organizations
When working in a health-care system or between two or
moreentities, the APRN may be confronted with replication
of the credentialing application process for each entity.
This can be extremely time consuming and result in lost
opportunities. It is important to gather perceptions from
be aware of the information and reference data about
activities that are required to be verified as part of the
credentialing process. Losing track of certification and
licensure renewals has immediate repercussions for the
credentialing process. Determining the accuracy of any
inputs into the NPDB or other databases is important
to verify before an institutional query on the APRN
occurs. Opportunities to correct information are less
stressful when the APRN is not abutting an institutional
Decreasing Barriers to Continuity of Care
Although the numbers of APRNs holding hospital privileges has accelerated, two reasons stand out as rationales
to seek out and obtain privileges that will help to decrease
barriers to continuity and seamless patient care. One is
that some insurance companies and MCOs require their
primary care provider (PCPs, or in this case APRN) to
hold hospital privileges as a prerequisite to credentialing
and billing or receiving payment. The other is that a PCP
who does not have privileges within a hospital cannot
review the chart or care provided for a patient once
that patient is admitted to the hospital. Although the
provider may make a friendly visit and ask questions of
the patient, he or she cannot validate or follow the treatment, tests, and outcomes in the patient record because
of the Health Insurance Portability and Accountability
Act (HIPAA). Being the provider of record and in many
cases the one who will eventually continue to follow that
patient upon discharge would make that transition back
to the community a much more seamless process. This is
especially important for independent NPs who carry their
own panel of patients and is also complicated by the fact
that hospitals may not notify APRNs when one of their
patients is admitted. They may not identify the APRN
as the provider of record either, partly because of lower
reimbursement levels for the hospital. It is important
to emphasize to both the patient and his or her family
that they must inform hospital staff if admitted and to
notify the APRN of the admission. If the whole process
is more transparent and collaborative and the provider
can hit the ground running when the patient is once
again placed in his or her care, the patient will be the
one who benefits.

114 Unit 2 The Practice Environment
from a board-approved national certifying body. Graduate education includes the doctorate of nursing practice
(DNP) degree. The Comprehensive Care Certification
(CCC) for DNP graduates administered by the American
Board of Comprehensive Care (ABCC) and promoted
by Columbia University grants the Diplomate of Comprehensive Care (DCC) credential. It is currently not
an NCSBN-approved certification nor is it recognized
by the Consensus Document or joint dialogue group as
an appropriate certification for uniform regulation of
APRNs. The CCC examination is based on Step 3 of
the National Board of Medical Education Examination.
Adoption of the (NCSBN, 2008) allows the APRN role
and population focus to be regulated at the state level and
the specialization focus to be credentialed by specialty
organizations rather than by state licensure. The CCC
currently falls into the specialty certification realm.
The examination was first given in 2008 at which time
22 of 45 individuals taking the examination received the
credential. From the initial 2008 examination through
2012, 135 individuals took the examination for the first
time, with an average pass rate of 50.8% (range of 33%
in 2012 to 70% in 2011). Although no results have been
posted since 2012, the Web site indicates that the next
testing date is anticipated to be in 2017. See further
information at
APRN Representation on the Medical
Staff and Adjusting Bylaws
As APRN privileging becomes more common, the APRN
should seek governance representation on the medical
staff and ensure the medical staff bylaws embrace full
representation of APRNs. There are exemplars for this
movement: The Center for Advancing Provider Practices
(2016) reported that 54% of Medical Staff Credentialing
Committees have at least one APRN or PA as a member,
representing a growth of 186% from 2013 to 2015 in
APRN and PA representation among 37 organizations.
Early on in Ellenville Regional Hospital in New York,
an APRN, Bob Donaldson, was invited to review and
revise the medical staff bylaws; he was ultimately elected
president of the medical staff in 2009, with another
NP serving as secretary of the medical board (Hendren,
other providers and administrators about expectations
and ramifications for productivity given duplication in
processing of multiple credentialing applications. Create
a solution team to construct alternative approaches to
reduce redundancy and be prepared to gather support
from colleagues on alternative proposals to present to the
governing board. As discussed previously, maintaining an
online professional portfolio will also help. Providers are
reminded quarterly to update their information and attest
to its accuracy. Other regulations and organizations are
on the horizon to limit redundancy in credentialing and
privileging and streamline the business of health care.
Consulting the CMS rules and regulations intermittently
can facilitate your ability to meet the changes in processes
in a timely manner.
Uniform Adoption of the Consensus
Model for APRN Regulation
Although 2015 has passed, the number of states adopting all the components of the APRN Consensus Model
document is still low. However, it is difficult to evaluate
because there are multiple components that must be
addressed to fully comply and many require legislative
change. The NCSBN has been tracking states by each
component and scoring each state as it reaches compliance. In general, NCSBN is tracking recognition of all
four roles, graduate education, national certification, and
uniform titling (APRN). As of 2017, less than one-third
(1/3) of states have reached full compliance with all the
components of the Consensus Model (see the maps on
the NCSBN Web site at for the
latest details). Currently, credentialing requirements
for APRNs vary among states as to the mechanism for
title protection and scope of practice differences. The
NCSBN proposed that it is appropriate for APRNs to
be legally regulated through a second license for their
role and population focus because their activities are
complex and involve role and population competencies,
independence, and autonomy (NCSBN, 2008). Most
state models now require an application, RN licensure,
completion of a graduate degree with a major in nursing
or a graduate degree with a concentration in the advanced
nursing practice category, and professional certification

Chapter 7 Credentialing and Clinical Privileges for the Advanced Practice Registered Nurse 115
It is clear that credentialing and privileging are important
processes that can be time consuming, complex, frequently
changing, and influenced by multiple factors. But these
processes can have a significant impact on both the scope
of practice and economic status of the practitioner. As
you think about eventual changes in credentialing and
privileging, be aware that no change is insignificant. Each
change holds both personal ramifications and implications
for the profession as a whole. It is always wise to follow the
dialogue and plan around national regulatory initiatives
that will direct your scope of practice.
2011; As privileging
of APRNs continues to grow across the country, more
will assume positions and contribute to the leadership of
institutional privileging.
All 50 states currently address advanced practicein public
policy in some manner. For the most part, state boards
of nursing hold authority over advanced practice. Where
the prescription of medications is a sanctioned activity,
additionaleducation in advanced pharmacology is required.
By this arrangement many state boards of nursing have
deferred to the professions right to recognize its specialists
through certification and to develop and promulgate the
standards of practice on which certification is based.

The Kaleidoscope
of Collaborative Practice
Alice F. Kuehn
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Summarize the history of physiciannurse and nursenurse changing relationships
and collaborative efforts.
Describe the myriad aspects of collaborative practice.
Distinguish between multidisciplinary, interdisciplinary, intradisciplinary, and
transdisciplinary practices.
Identify the status of collaboration in each of the four advanced practice nurse
(APN) roles.
Describe a framework for collaboration (concept and components).
Explain the historic and current barriers to health professional collaboration.
Propose strategies for developing a successful collaborative team.
Compare the traditional and emerging collaborative practice models.
The future of nursing and health care depends on partnership. One of the four key messages of the Institute of
Medicine (IOM) report on the future of nursing states
that nurses should be full partners with physicians and
other health professionals in redesigning health care in
the United States (2011, p. 7). The adoption of the
APRN Consensus Model (APRN Joint Dialogue Group,
2008) is identified as a key factor in regulatory change,
noting that the resulting consistency in regulation of
advanced practice nursing across states is facilitating
steady progress in legislative reform (Pearson, 2011;
Phillips, 2011). In Phillipss 2016 report, although

Chapter 8 The Kaleidoscope of Collaborative Practice 117
Our world continues to change so rapidly that change
itself has become the constant. This sense of change in
every aspect of life was described by Alvin Toffler in his
classic 1970 publication Future Shock, a term he created to
describe the shattering stress and disorientation resulting from too much change too quickly. Our response to
change has historically been slower than the change itself.
However, with todays rapidly increasing pace of change,
the lag between the change and our response is growing,
and this is what Senge (1994) calls future shock. Much of
our human behavior flows from our ability to embrace
or to fight the pace of life. Ours is a world of transience:
a series of short-term relationships with people, things,
places, workplaces, and information itself. In a situation
in which the duration of relationships has been shortened,
our sense of reality and of commitment and our ability to
cope are seriously challenged. The flow of change is not
linear, and we are being forced to adjust to novel situations
for which we have not been prepared. Because we are
living in a health-care world demanding collaboration,
cost effectiveness, and high-quality care, the relationships
among professionals are rapidly changing, demanding
flexibility and collegiality. A key recommendation of
the IOM report Keeping Patients Safe: Transforming the
Work Environment of Nurses (2004) was for health-care
institutions to move away from a hierarchal approach to
shared decision making and increased support of interdisciplinary collaboration. It should be noted here that
the Patient Protection and Affordable Care Act (PPACA)
introduced in 2010 has had a major impact on the manner
of health-care delivery today and continues to influence
the development of new more collaborative models of
care. However, although it supports efforts to increase the
number of APNs, there remain challenges to the delivery
of care by APNs because of continuing inconsistencies
between federal and state policies resulting in practice
restrictions (Carthon & Sarik, 2015).
PhysicianNurse Relationships Over Time
In 1859, Florence Nightingale described the role of
nursing as a specific set of relationships to medicine and
hospital administration set within the social structure of
22 states plus the District of Columbia (DC) now
allow for full NP scope of practice (SOP), meaning no
collaborative agreements with a physician are required,
28 states still require some sort of agreement for prescribing and advanced clinical practice. Phillips noted that
there were significant state legislative accomplishments
in the areas of APRN practice authority, reimbursement,
and prescriptive authority. During the past year, exceptional progress continued through strong and successful
partnerships made possible by APRN professional associations, Boards of Nursing (BON), and the Future of
Nursing: Campaign for Action (p. 21). Current trends
in health care reflect an ever-increasing call for collaboration, consensus building, coordinated care, and shared
decision making (SDM) as new models of care delivery
such as medical homes, nurse-managed clinics, SDM,
and accountable care organizations (ACOs) continue to
emerge (American Nurses Association [ANA], 2010b;
Haney, 2010; Hughes, 2011; McCarter et al, 2016;
Rice et al, 2010). In the ANAs Social Policy statement,
collaboration is described as a partnership in which
all partners are valued for their expertise, power, and
distinct areas of practice. The statement also acknowledges their shared areas of practice and mutual goals and
emphasizes that the nursing profession is particularly
focused on establishing effective working relationships
and collaborative efforts essential to accomplishing its
health-oriented mission (ANA, 2010b, p. 7).
The role of the APRN has evolved along a continuum of collaborative interactive models of increasing
complexity (Kuehn, 1998). Just as a kaleidoscope creates
a constantly changing set of colors and patterns, collaboration is a constantly changing aspect of health-care
practice, moving from little interest to a great demand,
from frustration to success, and sometimes back again.
The interactions among members of a health-care team
present a new picture each time the group, situation,
time, or environment changes. This chapter reviews the
history and examines myriad aspects of collaborative
practice. It compares and contrasts multidisciplinary,
interdisciplinary, intradisciplinary, and transdisciplinary
practices, using examples to clarify the distinctions and
similarities. The values, barriers to, and strategies by which
collaborative practice is being developed are presented and
the continuing and expanding evolutions of collaborative
practice models are examined.

118 Unit 2 The Practice Environment
the times. Placing the nurse as a care provider subservient
to the physician established and formalized a role structure
that, after nearly 150 years, continues to define societys
general sense of the nurse role as within the role of the
physician (Partin, 2009; Workman, 1986). A statement
issued at the 2009 American Medical Association (AMA)
House of Delegates meeting supporting this hierarchical
role structure called for physician supervision of nurses,
noting that the nurse role, even though it is important,
must be supervised. The nursing response drafted by the
ANA and some APRN organizations stressed that the
concept of physician supervision of APRNs is out of
date, is inappropriate, and creates a major barrier to the
access of care (Partin, 2009; Sorrel, 2009). The challenges
physicians face in understanding, supporting, and embracing the reality of the advanced practice role is a result of
cognitive dissonance, a rejection or denial of information
that challenges their preconceptions of the nurse role.
In examining the historical roots of collaborative
experiences between physician and nurse, the years between 1873 and the 20th century saw the relationship
of nurse to physician become more a scenario within a
hospital setting. The triad of physiciannursehospital
superintendent never truly evolved in equilibrium as the
Nightingale model envisioned because the scenario of a
nursing superintendent reporting separately to the hospital
trustees challenged the deference given to physicians and
administrators in practice and would have undermined
both their authority and the use of student nurses as
workers. The ongoing development of hierarchical relationships within the hospital between physicians, nurses,
and administrators resulted also from changes occurring
in nursing itself. Nursing sought to gain more professional
status through a rigid hierarchical management style of its
own within a continuing hospital attitude of paternalism
(Markowitz & Rosner, 1979; Reverby, 1979, 1987).
Collaborative relationships with physicians, hospitals,
and foundations serving the health-care system began to
develop during and following the Great Depression as
evidenced by the following: medical society participation
in the Committee on Nursing of the Association of American Medical Colleges as they endorsed the Committee
on the Grading of Nursing Schools; a manual on hospital
nursing service administration, sponsored by the American
Hospital Association (AHA) and the National League for
Nursing Education (NLNE), published in 1935; and a
survey of nursing schools in psychiatric hospitals under the
auspices of a joint committee approach by the American
Psychiatric Association (APA) and the NLNE. It should be
noted, however, that these examples are not of individual
collaborative relationships but of organizations, and were
tenuous at best; the medical society withdrew from the
Committee on Nursing shortly after their endorsement
(Roberts, 1959).
The ANA code of 1950 spelled out a relationship of
nurse to physician as a complex mix of dependent and
independent responsibilities. Roberts (1959) stated, The
nurse is obligated to carry out the physicians orders intelligently, to avoid misunderstandings or inaccuracies by
verifying orders, and to refuse to participate in unethical
procedures (p. 563). However, if every nursing decision
made must come from within the orders flowing from
another profession, the relationship cannot be collaboration but instead becomes supervised delegation. Kinlein
(1977) identified the dilemma in nursing as a blockage of
the ability of nurses to initiate nursing diagnoses, design
nursing care, or establish a distinctive practice when the
power of the medical judgment is the prime source of all
decision making regarding patient care. Nursing judgments
thus become delegated medical judgments because they
are aimed at a medical goal and have to agree with that
goal. Kinlein describes an example of a physician snatching
a chart from her hands while she was teaching a student
regarding a treatment regimen. The doctor stated, What
are you doing, talking about that? Thats none of your
concern. Just teach those students to give bedpans and then
to remove them (1977, p. 30), leaving both nurse faculty
and student to conclude that either the nurse has to learn
more and become a doctor or learn less so that he or she
is prepared merely to carry out orders. In this situation,
Kinlein notes, the nurse was expecting the physician to be
knowledgeable, the patient expected both physician and
nurse to be knowledgeable, and the physician expected
the nurse to have no knowledge. This is an unacceptable
situation, as well as a clear example of noncollaborative,
unidisciplinary practice, with no communication between
the two sets of providers except through a hierarchical,
supervisory relationship.
The current system of care delivery has been described
as supporting professional individualism and separatism of
roles, often resulting in defensiveness, lack of continuity,
competition, redundancy, excessive costs, fragmentation,

Chapter 8 The Kaleidoscope of Collaborative Practice 119
disciplines, policy makers and legislators, and the public. As
each of the four APRN practicescertified registered nurse
anesthetists (CRNAs), certified nurse-midwives (CNMs),
clinical nurse specialists (CNSs), and nurse practitioners
(NPs)has moved toward autonomy in practice, establishing positive relationships with the medical community
has been key. Stanley (2005, p. 34) notes that consumer
satisfaction and physician advocacy have proved to be
powerful stimuli for operationalizing the APRN role.
Applying Benners (1984) competencies and domains of
nursing practice from novice to expert levels to advanced
practice, Fenton and Brykczynski (1993) identified additional domains and competencies and verified the high level
of expertise of APRNs. However, the SOP flowing from
this model of expertise needs to be clearly identified. It is
critical for the practice of all APRNs, while maintaining
clinical practice distinctions, to be conceptually united,
stressing commonalities while acknowledging differences
in practice patterns but promoting an interdisciplinary
focus in their practice (Stanley, 2005). Once the role is
clarified, SOPs delineated, common practice elements
of APRNs made known, and support from professional
colleagues and consumers ongoing, the challenges faced in
establishing collaborative practice will be greatly minimized.
This is the hope of the APRN Consensus Model (APRN
Joint Dialogue Group, 2008). Without these foundational
components, the challenges of creating truly functional
teams will continueto besignificant. The following section
provides a brief overview of role development challenges,
achievements, and approaches to collaboration for each
of the four APRN practices as well as three additional
provider roles affecting primary care delivery: the PA,
pharmacist, and the patient navigator.
The Certified Registered Nurse Anesthetist
Clarity of role and a reach for autonomous practice were
forged early in the development of nurse anesthetists.
In a study of surgeonnurse anesthetist collaboration in
surgery between 1889 and 1950, Koch (2015) noted that
the success of nurses in anesthesia duty during the Civil
War led to the formal collaboration between nurses and
surgeons at the Mayo Clinic and the beginning of a long
and continuing surgeonnurse collaboration that helped
advancesurgery in the United States. Alice Magaw, a pioneer
in the field who worked at the Mayo Clinic in the early
1900s, supported the separation of nurse anesthesia from
little cooperation or teamwork, grossly inadequate and
outdated systems of communication, and underutilization
of APRNs (Fischman, 2002; Goodman, 2007; IOM, 2011;
Norsen, Opladen, & Quinn, 1995; ONeil & Pew Health
Professions Commission, 1998; Spitrey, 2016). However,
calls for collaborative practice have continued to grow
and intensify, requiring physicians, nurses, and all health
professionals to begin working through the relationshipbuilding process required to establish a collaborative team
approach. Pearson (2011) noted that the irony of our
continuing struggle with organized medicine is that, even
while we fight against medicines inappropriate domination over our practice, we must maintain and enhance
our working relationship with individual physicians, for
patients are best served when providers work together
(p. 22). This requires a team effort within an environment
of mutual respect and valuing of each professionals role.
As Cooper reminded us, Ultimately, the success of each
discipline will be judged by how effectively it participates
in a continuum of care that meets the needs of patients
and of the health care system overall (2001, p. 58).
The credible evidence showing that collaboration
improves health care outcomes for patients entreats the
two professions to put cooperation before professional
roles (Phillips, Green, Fryer, & Dovey, 2001, p. 1325).
An increasing number of health-care studies continue to
affirm the need for and value of collaboration,emphasizing
that efficient delivery and high quality of care may depend
on the level of collaboration among professional care
providers (Donald et al, 2009; Hojat et al, 2003; Hughes,
2011; Rice et al, 2010; Zwarenstein & Bryant, 2000).
Maier and Aiken (2016), in examining the expanding
clinical roles for the nurse globally, noted that the focus
of research and policy debate in the U.S. is shifting away
from whether NP-provided care is safe, to how to reduce
barriers to practice and maximize access for those most
in need (p. 2, italics added).
Status of Collaborative Practice
in Advanced Practice Roles
The growth and acceptance of the APRN role has hinged
on the willingness of the profession to acknowledge and
support therole; provide advanced education and experience;
and promote a clarity of role that facilitates development
of a sense of identity and clear understanding by other

120 Unit 2 The Practice Environment
of the anesthesia team while working together to continue
the advancement of surgery (Koch, 2015).
The Certified Nurse-Midwife
In the colonial and pioneer history of the United States,
midwives wererespected members of both settler and Native
American communities. However, since the early 1900s
the role has had a stormy history caused in no small part
by the low status of women, sparse education, religious
intolerance, and increased domination of physician obstetricians with the movement toward birthing in hospitals.
In 1921, the Maternity Center Association of New York
and the Henry Street Visiting Nurse Association proposed
establishing a school of nurse-midwifery. However, strong
opposition from medicine, nursing, and the public arose,
mainly because of a generally held negative view of the role
of midwife as an exemplar of inadequacy, little education,
and social incompetence. In 1925, the role moved to a
new level of recognition and respect with the inauguration
of the Appalachian clinics of Kentucky (Frontier Nursing
Service) by Mary Breckenridge(Dorroh & Norton, 1996).
The number of CNMs has increased from just 275
in 1963 to more than 4,000 by 1995 and 7,000 in 2011
(American College of Nurse-Midwives [ACNM], 2011).
CNMs consider interdisciplinary practice as a sine qua
non of their practice, and this position has been affirmed
in their standards of care and formal definitions of practice (ACNM/ACOG, 2002). In 1971, the ACNM, the
American College of Obstetricians and Gynecologists
(ACOG), and the Nurses Association of the ACOG issued
a joint statement supporting the concept of obstetrical
team practice. However, the teams were to be directed
by a physician, formalizing a hierarchical practice pattern
that continues to pose challenges to development of a
collaborative approach to practice (Bigbee, 1996). The
ACNM statement on collaborative management defines
collaboration as the process whereby a CNM or certified
midwife (CM) and physician jointly manage the care of
a woman or newborn that has become medically, gynecologically or obstetrically complicated (ACNM, 1997).
The need for collaboration is indicated by the health status
of the client rather than by statute or edict. However, the
number of viable practices currently differs considerably
state by state because of legal and legislative requirements
for collaboration and the parameters of required collaborative practice protocols, which vary from state to state.
nursing service administration, emphasizing its need for
recognition and requirements for specialized education.
During World War II, the role was identified as a clinical
nursing specialty within the military field, and in 1945 a
formal national certification process was established. The
SOP of the CRNA has been described by the American
Association of Nurse Anesthetists (AANA) as a practice
in collaboration with legally required professional healthcare providers. This description noting a legally required
collaborator has led some to regard the legal status of
nurse anesthesia as a dependent function under physician
control and continues to result in considerable challenges
in development of a high-level collaborative practice
model (AANA, 2006; Bigbee, 1996; Faut-Callahan &
Kremer, 1996; Taylor, 2009). Some states use the term
collaboration to define a relationship in which each party
is responsible for his or her field of expertise while maintaining open communication on anesthetic techniques.
Other states require the consent or order of a physician
or other qualified licensed provider to administer the anesthetic. The Centers for Medicare and Medicaid Services
(CMS) required physician supervision for nurse anesthetist
services to Medicare patients. However, in late 2001, a
rule published in the Federal Register allowed a state to
be exempt from this physician supervision requirement
for nurse anesthetists after appropriate approval by the
governor. By 2007, 14 states had opted out of this federal
requirement (Blumenreich, 2007, p. 93). Recent literature focuses on the term anesthesia care team (ACT) to
indicate a practice by a CRNA with an anesthesiologist in
a medically directed environment. Jones and Fitzpatrick
(2009) identified four possible types of current inpatient
anesthesia team arrangements in the United States: an
all-anesthesiologist staff, an all-nurse anesthetist staff, a
mixed staff of the previous two, and a team of anesthesiologist and anesthesiologist assistants (p. 431). In their
study of collaboration among members of these teams,
they found satisfaction with collaboration expressed by
both nurse-anesthetists and physicians. However, they
noted that there are still issues with role conflict; unclear
expectations and limits on SOP with mixed teams; and
a component of exclusion from hospital, departmental,
and anesthesia group responsibilities when only physicians
can participate in hospital committees or represent the
group. The challenge for CRNAs is to work with physician
colleagues to achieve fullness of practice for each member

Chapter 8 The Kaleidoscope of Collaborative Practice 121
joint statement wasendorsed by both parties as a document
that promotes respect and collaboration between CNMs/
CMs and [medical doctors] and encourages individual
practices to work collegially together to meet the needs
of individual patients (Shah, 2002, p. 2). The simplicity
of the statement was perhaps its greatest asset. By not
dictating specific protocols or responsibilities, professional
accountability is placed whereit rightfully belongs: on each
respective profession and the individual womens health
care professional (p. 3). The most recent joint statement
of the ACNM and ACOG alliance in 2011 reaffirms their
shared goals regarding womens health and continues its
simplicity of language and approach,emphasizing the need
for a health-care system that facilitates communication
among providers and across settings (ACNM/ACOG, 2002).
The positive take on this statement, the review of APRN
outcomes by Newhouse and colleagues (2011) confirming
the high-quality care delivered by CNMs in the United
States, and the evidence provided by the 2012 American
Midwifery Certification Board noting that nearly 50% of
recent CNM/CM grads were providing some primary care
services either independently or collaboratively stress the
continuing need for developing collaborative approaches
in the practice setting as well as for greater clarity of SOP
(Phillippi & Barger, 2015).
The Clinical Nurse Specialist
The CNS role, which originated in the late 1930s, was
formalized as a nurse-clinician to be prepared in graduate
nursing programs. Itsemergencerepresented a major shift of
focus in graduateeducation from the choice of a functional
role of primarily teacher or administrator to the selection
of a clinical specialization in practice. Of the multiple
specialties represented by the CNS role, psychiatry was
the first to move to graduate education and is among the
most highly respected. Some have attested that collaborative
activities with physicians seemed to come more naturally
for this group because of their graduate-level education,
which allowed CNSs and physicians to more readily relate
to each other as peers (Bigbee, 1996). A review of literature
published between 1990 and 2008 on care provided by
CNSs gave supporting evidence of their value in acute
care settings in reducing length of stay, cost, and rates of
complications (Newhouse et al, 2011).
Key elements of CNS practice identified by the American Association of Critical-Care Nurses (AACN, 2007)
Because of lack of support from physicians and hospitals, CNMs are often unable to practice or their practice
is severely limited because of economic competition and
differing views on the meaning and value of collaboration.
A study from New Zealand offers a model of midwifery
carein which midwifery-led maternity careis the dominant
model and 75% of the New Zealand women choose a
midwife as their lead maternity caregiver (LMC). When
midwives did refer to an obstetrician, 74% indicated
they continued providing care in collaboration with the
obstetrician and the relationships between professionals
were satisfying (Skinner & Foureur, 2010). This model
starkly contrasts with the description by Goodman (2007)
of the marginalization of certified nurse-midwives in the
United States where in 2007 midwives attended only
7% of births.
The issue of economic competition is another hindrance to CNM practice. In a conversation between a
nurse-midwife and an obstetrician with whom she had
a good working relationship, the physician commented,
I dont have any problems with you personally, but the
fact is that my practice is not full, and until it is there is
not going to be a nurse-midwife that will get privileges
at this hospital (Goodman, 2007, p. 616). Another economic factor threatening the future of the collaborative
relationship is malpractice insurance cost. For example,
in a discussion with one CNM/physician practice group,
the CNMs noted that the cost of malpractice insurance
increased from $18,000 to $40,000 during 1 year, and
their practice group could not afford to cover the additional costs. Individual CNMs did not get paid for all
the calls they took, nor were they able to attend enough
births to cover the cost of their own insurance. This inequity of practice compensation coupled with the lack of
100% support of a practice by their physician group
resulted in the midwives no longer practicing midwifery
but being limited to providing otherwomens health services.
In October 2002, the joint statement between the
ACNM and the ACOG was revised for the fifth time in
30 years. An ongoing concern of many CNMs and physicians had been the language and the inferences of previous
documents readily open to multiple interpretations. The
leadership of ACNM and ACOG decided to develop a
statement more reflective of the current status of each
profession, as well as contemporary realities within the
womens health-care system. The 2002 ACNM/ACOG

122 Unit 2 The Practice Environment
varied ways in which the role has developedcoming
from certificate programs, many within medical schools,
and gradually moving into graduate nurse programsthe
history of collaboration is a patchwork quilt. Support of
and opposition to the role has come from both medicine
and nursing. Martha Rogers (1972) opposed the role as
demeaning to nursing in deference to medical practice,
and this view, supported by many nurse educators at the
time, created serious divisions within the nursing profession
as NP educators worked to enhance the role and move it
into graduate-level education. Medical opposition, which
existed from the beginning, is often couched in terms of
patient safety, despite the fact that it often is more related
to issues of control and competition in practice. Because
of these powerful sources of opposition, the focus on
collaboration has been both a boon and a boondoggle to
NP practice. The importance of the interdisciplinary team
and the responsibility of the NP to assist in collaborative
team development have been consistently emphasized
(Buerhaus, 2010; Hanna, 1996). However, as the term
collaboration found in some state nursing practice acts
often conveys a concept of supervision, there are many
who would strike the word from any statutory documents.
The evolving acute-care NP (ACNP) role requires a very
explicit differentiation of medical and nursing domains
within a collaborative practice. Strong support from nursing
serviceand better yet, having the ACNP housed within
the nursing departmentallows for easier differentiation
of role by each partner. This promotes a team in which
each partner comes from a solid professional sense of self
and can then join with others to fuse into an autonomous,
interdependent team of providers. In contrast, when the
ACNP is supervised by a resident or is employed by a
medical specialty department, it becomes more difficult for
the practitioner to participate equally in decision making
and to be considered a full partner in the practice (Lott,
Polak, Kenyon, & Kenner, 1996).
The role of the NP within managed care systems has
evolved into a process of collaboration, coordination, and
negotiation, requiring the creation of new relationships
among a wide range of personnel. Role negotiation is a key
component of this type of practice, in which the required
interaction between professionals for the specific purpose
of changing the others expectation of ones role can result
in increased job satisfaction, reduced role conflict, and a
more positive team relationship (Miller & Apker, 2002). A
include collaborating with other disciplines to provide
interdisciplinary best practices (p. 7). Collaboration is
one of the eight CNS competencies considered essential
for nurses providing care in the acute-care setting. These
competencies are part of the AACN synergy model for
patient care, recommended as a guide for clinical practice
in acute care. The model is predicated on the fact that
patient outcomes are optimal when patient characteristics and nurse competencies are in sync (Kaplow, 2007).
One CNS described her collaborative practice level as a
real partnership with a great deal of mutual caring and
respect between providers. Each partner grounded interactions in self-confidence and personal mastery, and they
planned together always. Yet another CNS noted that
her collaborating physicians needed some education on
what the CNS could and could not do, but they learned
as they jointly practiced, and a real comfort level occurred
after about 6 months. A hematology-oncology APRN
group, which formed a successful collaborative practice
over a period of 7 years, identified effective leadership
and shared development of goals and communication as
critical for establishment of a viable structure (Schaal et al,
2008). Another collaborative partnership of the CNS and
the nurse manager of an oncology unit described the key
element of success as development of mutually acceptable
goals (Gaguski & Begyn, 2009). In 2016 Spitrey reported
on the reaction to the Department of Veterans Affairs
proposal to allow full practice authority for all APRNs
working within the VA system as a means of increasing
veteran access to care. She noted the resistance is still
strong in some sectors despite nursings track record of
safe and effective advanced nursing care delivery. The key
to the future of a positive and productive collaborative
practice for all APRNs with physicians and other health
professionals is a relationship that becomes more mutually
valued and partner driven.
The Nurse Practitioner
The role of the NP has been described as an innovative
role in primary care, grown from the role of the public
health nurse and possessing a high degree of autonomy
in practice (Bigbee, 1996). Since its inception in the
1960s, a considerable expansion of the concept of the NP
role has occurred, as NPs have moved into a multitude
of settings that are not necessarily primary care such as
long-term and acute care. Because of the unique and

Chapter 8 The Kaleidoscope of Collaborative Practice 123
practice rights for APRNs does not come from any federal
action so much as from state legislative changes. Despite
challenges to NP practice, their value is continuing to
be acknowledged and the health system delivery process
is changing and requiring a greater focus on teamwork
(Maier & Aiken, 2016).
The Concept
Collaboration is a dynamic, transforming process of
creating a power-sharing partnership (Sullivan, 1998,
p. 6). As a dynamic process, it includes the flexible
distribution of both status and authority, and requires
both relationship building and shared decision making.
A distinctive interpersonal process, it requires that the
partners recognize and acknowledge their shared values
and commit to interact constructively to solve problems
and accomplish identified goals, purposes, or outcomes.
Using the consensus process, where participants are not
coerced as in compromise or majority vote but helped to
reach an agreement they can approve, even if they do not
agree with all points, facilitates high levels of agreement
and team satisfaction. Shared power, a key component
within a collaborative practice, requires the active contribution of each participant, respect for and openness
to each others contributions, and use of consensus in
forming new approaches to practice that use the strengths
of each participant (ANA, 2010a; APRN Joint Dialogue
Group, 2008; IOM, 2011; OBrien, Martin, Heyworth, &
Meyer, 2009; Rice et al, 2010).
The Components
A viable and high-level collaborative practice may be readily
identified by the existence of four essential components:
separate and unique practicespheres, common goals, shared
power control, and mutual concerns. Table 8.1 presents
the components essential for a positive practice, the key
attributes of a highly collaborative practice, and practitioner
competencies contributing to success. A phenomenological
study of how APRNs and physicians perceive and describe
their sense of collaboration identified four key behaviors as
essential for collaboration: approachability, interpersonal
professional partnership promoting collaboration replaces
competition with shared responsibilities in which each
partner brings a unique and necessary set of knowledge
and skills to the practice. The fear of loss of professional
uniqueness is met head on by a practice in which the expertise and unique abilities of each team member, when
combined into a synchronous whole, deliver a high level
of care not possible through the efforts of a single provider
(Norsen, Opladen, & Quinn, 1995).
A review of two rural Ontario primary care practices
consisting of NPs and family physicians (FPs) found
comparable involvement of both in health-promotion
activities and considerably greater focus of NPs on disease
prevention and supportive care. However, the review also
found NPs were underutilized in relation to curative and
rehabilitative services, with referral patterns being largely
unidirectional from NP to FP. The authors noted that
such a one-sided referral process does not reflect collaboration, which demands shared, reciprocal practice patterns
(Way, Jones, Baskerville, & Busing, 2001). In addition,
the regulated drug list required for Ontario NPs does
not permit NPs to renew medications for stable chronic
illnesses, limiting their SOP and hampering the ability
of the NP to assist patients in the management of their
chronic illnesses (Way et al, 2001). Rationale offered
for drawbacks to a full collaborative practice included
unclear medico-legal issues affecting the ability to share
responsibility, an absence of interdisciplinary education
at both undergraduate and graduate levels, and lack of
knowledge and practice experience regarding the scope
of NP practice. The Missouri Nurses Association (2011)
reported that the health-care access and needs of rural
Missourians were currently strained and any discussion
of solutions must include considering the role of NPs and
physician assistants (PAs). They stressed that the future
economic stability and health status of rural Missourians
depends on . . . [considering] options that allow for increased use of the expertise of advanced practice registered
nurses (Becker & Porth, 2011, p. 9). Panelist Charlene
Hanson summarized the state of NP practice when she
noted that physicians and NPs at the grassroots have
worked out a comfortable, collaborative, professional
relationship that benefits both. But the relationship at
the policy and organizational state and national levels
is much more divisive (Buerhaus, 2010). Expanding
this thought, Marshall (2016) noted that obtaining full

124 Unit 2 The Practice Environment
skills, listening, and verbal message skills, each of which
reflects either the attributes or competencies identified by
OBrien, Martin, Heyworth, and Meyer (2009).
1. Separate and unique practice spheres. Both physician
and nurse must identify components of their practice
that are separate and unique (SOP) and components
that they share. A high-level collaborative practice
requires an autonomous, trusting relationship within
which bilateral consultation and referrals are the norm.
Autonomy exists within each practitioners skill and
competence and allows for confident decision making.
It is the trust of the team that empowers that person to
practiceindependently within his or her defined scope of
practice. As one APRN noted, You must be willing to
expand your boundaries but know your limitations and
where you feel comfortable in your practice (Bailey &
Armer, 1998, p. 243). The existence of bidirectional
referral and consultation reflects a high level of trust
between practice partners. In oneinstance, the physician
response to a consultation request was, Now this is
not what you have to do; this is what Id recommend.
But the final decision is yours because its your patient
(Bailey & Armer, 1998, p. 243).
2. Common goals. When both partners agreeto responsibilities
for practice goals, the partners are well on their way to
a synchronous relationship. As one provider in a highly
collaborative practice noted, Care by all providers is
based on mutually defined goals of the practice (Bailey &
Armer, 1998, p. 245). All the participants cited by
Bailey and Armer (1998) stressed that responsibility
for patient outcomes was the key driving force in their
collaborative actions. One APRN noted, If theres a
patient [I treated] who calls in and . . . says Im just
not better, shell [the physician] say things like If I had
treated you, I would have given you the same thing.
It just sets the patient at ease because they realize that
were working together (p. 245).
3. Shared power control. Each physician and nurse partner assumes individual accountability along with a
shared responsibility for actively participating in the
decision-making process as well as supporting the
consensus-driven decisions and sharing in their implementation. In one situation, a nurse, commenting
on a physician perceived as very collaborative, stated,
We started when the MD and PA called me to discuss his patients care and asked for suggestions. . . .
We examined the patient together, the MD described
Table 8.1
Components of Collaborative Practice
Essential Components Key Attributes Competencies
Separate and unique practice spheres or
scope of practice
Common goals
Shared power control
Autonomous, trusting relationship
Confidence in a partners skill
Bidirectional referrals and consultation
Communication skills
Conflict management
Mutual concerns Consensus-driven decision making Coordination
Equitable reporting lines and evaluators Clinical skills
Mutual respect
Mutually defined goals of the practice Decision-making skills
Positive attitude
Open, informal communication
Parity between providers (physical space,
caseload, and support staff)
Positive support by colleagues, support
staff, and consumers
Willingness to dialogue

Chapter 8 The Kaleidoscope of Collaborative Practice 125
exist, assertiveness becomes threatening, responsibility
is avoided, communication is hampered, autonomy is
suppressed, and coordination is haphazard (Norsen
et al, 1995, p. 45).
The Intensity Continuum
The level of collaboration within a practice can be found
by identifying the intensity of professional relationships
(high to low) and the type of collaborative structure found
along a complexity continuum of unidisciplinary, multidisciplinary, interdisciplinary, or transdisciplinary practice.
See Figure 8.1. The interactive complexity of the practice
will increase as the structure becomes more complex,
offering greater challenges to the team but resulting in
even more positive and productive outcomes of practice.
Professional staff in any health setting (e.g., licensed
practical nurse [LPN], RN, social worker, APRN, physician, radiology technician, and so on) are coming from
a unidisciplinary base. As students, they were prepared
for the interactive world of practice within the security
of working with students, faculty, and practitioners of
their discipline and program. They begin to develop
personal mastery of professional knowledge and skill, an
essential requirement for functioning effectively at the
more complex levels of interactive relationships found
in collaborative practice. Educational experiences with
students of other professions are generally very limited,
usually to clinical encounters. As the professionals begin
to share responsibilities for the same patient or patient
populations, they begin to interact with each other and
a multidisciplinary practice model emerges. This is a level
of information exchange with no presumption of shared
planning. Each fulfills a discipline-specific role but communicates with others on an as-needed basis. This level
exemplifies the chimneys of excellence approach in
which work is accomplished not by team effort but by a
collection of professionals working for the most part in
isolated splendor (Kuehn, 1998, p. 27). However, within
this multidisciplinary framework, an interdisciplinary relationship can begin to develop as two or more members
begin to coalesce their roles toward a common vision or
goal. There begins to be a sense of shared investment and
a desire to plan together for a better outcome. As each
professional shares discipline-specific expertise, crossfertilization of ideas starts to occur and group ownership of
what we were seeing in the wound . . . and I identified
potential strategies for wound healing. . . . The MD/
PA team acknowledged my expertise and came to me
for assistance to assist the patient (McGrail, Morse,
Glessner, & Gardner, 2008, p. 201). Ongoing and
consistent communication is key to building a sharedpower practice. Providers must be comfortable sharing
information about patient care, issues of collaboration,
and team functioning. Collaboration is a powerful tool
to build a team, but without shared decision making
collaboration cannot exist (Gaguski & Begyn, 2009;
Maylone et al, 2011; OGrady & Ford, 2009; Sullivan
et al, 1998).
4. Mutual concerns. To ensure mutual concerns are met,
providers need to haveskills of assertiveness, cooperation,
and coordination. Assertiveness can be described as the
ability to express a viewpoint with confidence and with
attention to being factually accurate and focused on
the patient need. The key aspect of team success is the
knowledge and utilization ofeach membersexpertise by
the others. For example, in a surgical care situation, the
physician is in charge of the operation; the physician and
NP or CNS jointly care for the patient postoperatively;
the NP or CNS is in charge of discharge planning;
and in some settings the CRNA might also be on the
surgical team, assuming full responsibility for anesthesia
delivery, each one confident in his or her skills and able
to speak up regarding patient needs and care direction
as he or she sees it. Acknowledgment and respect of
other opinions and viewpoints while maintaining the
willingness to examine and change personal beliefs and
perspectives stresses the interdependence of the practitioners on the team and underlies true cooperation.
Collegial relationships replace hierarchical authority
with equality and shared decision making. Decisions
made by consensus are based on the expertise of each
member; there are different levels of input, but it is
always in the best interest of the patient. One APN
noted, There are many times the physician will say
to me This is a nurse practitioner patient, and its
somebody that has all kinds of sociological problems.
Problems that I could coordinate, and thats good; thats
a compliment to nursing. He actually has learned what
we do (Bailey & Armer, 1998, p. 243). Trust is the
bond that unites all the components of collaboration.
Without the element of trust, cooperation cannot

126 Unit 2 The Practice Environment
complementary to the other(s). In contrast, interprofessional
describes unique disciplinary knowledge applied in the
service each discipline offers in a specific health situation.
Each professional comes to the situation with disciplinary
knowledge and one profession does not preside over the
others (p. 5). The second basic tenet of nursing practice
(ANA, 2010a) notes that nurses coordinate care by establishing partnerships . . . collaborative interprofessional team
planning is based on recognition of each disciplines value
and contributions, mutual trust, respect, open discussion
and shared decision-making (p. 4).
The intensity of relationships is at a peak when a
practice moves into a transdisciplinary level. It becomes a
practice without professional boundaries, a synthesis of
knowledge and practice. Here the practitioners are able
to rise above fears of being subsumed and the individual
visions of each become a shared vision with laser-beam
intensity. All, including the patient, own the plan of care
and the goal of high-quality patient care transcends any
the practice begins to emerge. The dynamics that revolve
around the emerging practitioner-to-practitioner relationships concern issues of leadership, power control, norms,
values, group behavior, and conflicts and demand skills
in communication, collaboration, and conflict resolution.
Major growth in the complexity of interactive practices can
be seen by the increased use of the terms interdisciplinary
and interprofessional to describe this third level of team
dynamics as a key requisite for high-quality care (American
Medical Directors Association [AMDA], 2011; Donald
et al, 2009; Parse, 2015; Rice et al, 2010). Parse (2015)
describes distinctive differences between interdisciplinary
and interprofessional, contrasting discipline as the body of
scientific knowledge that is the basis of that disciplines
practice and research with profession as those educated
professionals committed to the vision and purpose of
that vision. Interdisciplinary then refers to the joining of
two or more disciplines in educational courses or projects,
with each discipline preserving its uniqueness while being
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Figure 8.1 Intensity continuum.
(Data from Blais et al, 2002; Kuehn, 1998).

Chapter 8 The Kaleidoscope of Collaborative Practice 127
people from other disciplines and healing traditions. The
key to team building is the affirmation by all of a shared
mission, tasks, goals, and values (ANA, 2010a; IOM, 2004,
2011; Jehn, Northcraft, & Neale, 1999; Senge, 1994).
The Iceberg Effect
Where the team of APRN and physician falls on the
collaboration continuum, as well as the intensity of the
relationships, is determined by several critical factors. These
factors can be visualized as an iceberg, with many factors
visible and openly known and others that remain invisible
or unacknowledged although still extremely significant in
their effect on the success or failure of the collaborative
effort (Pearson & Jones, 1994; Plant, 1987). See Figure 8.2.
The formal visible systems include many common
components of practice such as organizational policies,
clinic objectives, systems of communications, and role
or job descriptions. These are accessible and changeable,
and are readily addressed in open, rational discussion.
In contrast, the invisible, informal systems, including
power networks, values, and norms, are not as accessible
but subtly present, difficult to change, and often give
a sense of being untouchable. Many of the barriers to
collaboration are hidden here. Only through working
together can a team become aware of the impact of this
invisible system and work to eliminate the barriers. The
barriers must first be identified and acknowledged, and
then strategies applied to remove or neutralize them as the
partners in practice work to become a viable team (Donald
et al, 2009; IOM, 2011; Maier & Aiken, 2016; McCarter
et al, 2016; Paradise, Dark & Bitler, 2011).
Barriers to collaboration hinder positive change and growth
in our health-care system, frustrate the professionals trying
to work as a team, and can negatively affect the future
of health care (IOM, 2011; Kubota, 2011; Rice et al,
2010). Key barriers that continue to challenge collaborative efforts include educational isolation, professional
elitism, organizational hierarchy, unrecognized diversity,
expanding scopes of practice, role and language confusion,
inadequate and inappropriate communication patterns,
and professional dissonance.
turf issues. As the number of participants increases, the
resulting diversity, complexity, and intensity of relationship
building requires that each participant feel that he or she
owns the vision. The critical indicators of collaboration
are now a part of each and a visible part of the whole. At
this level communication through dialogue is the key to
success. Discussion, coming from the same root word as
percussion, implies a hard exchange of ideas bouncing back
and forth, presented and defended with the need to come
to a decision. In contrast, the art of dialogue allows for
free exploration of ideas, issues, and innovations, with no
sense of defensiveness and the ability to suspend personal
viewpoints. When a team arrives at this point, they become
in such close alignment that when working together they
enter the transdisciplinary stage of collaboration in
which they act as one and do not have to think about it.
Senge (1994) offers an example using the Boston Celtics, a
basketball team that won 11 world championships in just
13 years. The famed Celtics center Bill Russell described
their team play not as friendship, but as a synchronous
relationship among the players. He stated (p. 234) that
sometimes during a game, it would
heat up so that it became morethan a physical oreven mental
game . . . and would be magical. . . . When it happened I
could feel my play rise to a new level. . . . It would surround
not only me and the other Celtics but also the players on the
other team, and even the referees. . . . At that special level,
all sorts of odd things happened. The game would be in the
white heat of competition and yet I wouldnt feel competitive,
which is a miracle in itself. . . . The game would move so fast
that every fake, cut and pass would be surprising, and yet
nothing could surprise me . . . during those spells I could
almost sense how the next play would develop and where the
next shot would be taken.
To develop positive relationships with other health-care
practitioners, comprehensive care requires the collective
contributions of many varied professionals with highly
developed skills, including self-knowledge and traditions
of knowledge in the health professions; team and community building; and work dynamics of groups, teams,
and organizations. Practitioners must be familiar with
the healing approaches of other professions and cultures,
be aware of historic power inequities across professions,
identify similarities and differences among traditions of
community members, know the value of the work of others,
and learn from having had experiences of working with

128 Unit 2 The Practice Environment
understand the contribution each profession makes to the
practice(Glasgow, Dunphy, & Mainous, 2010; Hojatet al,
2003). Interprofessional continuing education might focus
on team building or on a specific patient care problem,
helping health professionals acknowledge the value each
brings to the situation and focusing on the patient rather
than the discipline (Sauter et al, 2016; Trossman, 2014).
Professional Elitism
Educational isolationism easily leads to professional elitism as each profession educates its own with a sense of
importance and unique worth. Professionalism consists of
three components: professional ideals of knowledge and
service, the professional occupation and the life career
it provides, and the character of the work itself. The life
career is the vehicle through which the ideals are put into
practice, and the profession itself defines the character of
professional work. The commitment to healing and to
service is thereby limited by the definition of healing and
public service crafted by the profession. Although importance and worth are valued aspects of self-identity,
a pervasive sense of professional elitism running through
Educational Isolation
Despite an increasing call for an interdisciplinary approach
to education in the health professions, many educators
continue to use a traditional linear approach with built-in
assumptions of bureaucratic organizational structures,
standardized sets of relationships and roles, and systematized methods of record keeping, billing, and payment for
services. Past studiesexploring thestatus of interdisciplinary
education have noted many inherent problems associated
with developing interdisciplinary educational programs,
citing workload stress, intense workload demands, lack of
academic and institutional support, and often seemingly
insurmountable complications with clinical arrangements
(Kuehn, 1998). In the past, some nurse educators have
expressed concerns that the traditional concept of a nursing workforce is challenged by calls for health care to be
delivered by interdisciplinary teams, fearing that this focus
has the potential of obscuring the unique contribution
of nursing to health-care delivery (National League for
Nursing [NLN], 1997). However, shared educational
experiences can actually help clarify roles because as
faculty and students work together, they begin to better
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Chapter 8 The Kaleidoscope of Collaborative Practice 129
over a variety of other subordinate professions (Friedson,
1970). The two lines of authority in medicine and health
care have historically been the administrative authority of
the office and the medical authority of professional skills
and expertise. The medical profession as an occupation with
institutionalized privileges and authority granted by others
on a basis of faith and trust holds a special form of legal
power based on expert status because their knowledge
and work are considered very complex and nonroutine,
and subsequently has a position of dominance among
other occupations providing health care. This results in
professional control of information and suspicion of the
value of what lies outside their domain. Friedson (1970,
pp. 231, 234) suggests that this autonomy and dominance
need to be and can be controlled by an administrative
structure that stresses accountability for effective and
humane services and is responsive to the patient:
For a profession to be true to the ideal of a profession, members must let go of the total authority and control over the
terms and content of their work and cease total dominance
in favor of a division of labor. The physicians must temper
autonomy and dominance with administrative accountability,
accountability to the patient, self-regulated peer review and
encouragement of other providers to assume responsibilities
of health care . . . [However] no service using other providers
is possible . . . without the active cooperation of the dominant profession. If the profession does not trust them, or if
it resents and fears them, it will not refer patients to them,
nor will it graciously receive patients referred from them. . . .
Mere administrative fiat is not enough.
Supervision is defined as critically watching and directing
activities or a course of action and is a mainstay of any
hierarchical structure. Rationales given for supervision
of health care include documented inadequacy; lack of
knowledge, experience, or skills in relation to the person
supervised; legal requirements; a lack of trust or confidence
despite no legal limits requiring supervision; perceived
safety needs of patient or provider; and history, tradition,
or local institutional policy. In exploring the difference
between under the supervision of and ownership of
practice decisions, it may be most helpful to view them
not as polar opposites but as different levels of collaboration
along a continuum of autonomous practice. Kinlein (1977)
stressed that if a physician, a member of one profession,
determines by his or her orders what actions a nurse, a
member of a separate profession, will take, the practice is
this approach can result in the work of each professional
taking priority over helping each other or putting the
patients needs first (ONeil & Pew Health Professions
Commission, 1998). In his classic discourse on medical
dominance, Friedson (1970) claimed that the dominant
position of the medical profession in the health division
of labor allows it to reinforce and protect itself from
outside influence and to claim and maintain jurisdiction
and control over many more areas than logic or evidence
justifies. . . . It is professionalism itself that seems to
transform the ideal responsibility to serve the good of the
general public into a limited concrete responsibility to serve
the good of ones personal public (p. 152). As Friedson
(1970) cautioned, A professional who is so qualified as
to perform this extraordinary work of medicine . . . must
himself be a rather extraordinary, gifted, person . . . as are
his colleagues and his profession. . . . This professional pride
leads the worker to consider himself to be quite different
from, indeed superior to, those of other occupations. . . .
The thrust of professional activity becomes a mission to
build barriers that keep the profession and its clientele
safe from those beyond the pale while seeking jurisdiction over all that cannot be excluded (pp. 154155). In
a recent intervention study to improve interprofessional
collaboration, physicians reported that they expected
orders would be carried out without discussion. Nurses
and other health professionals in the study agreed that this
was the medical expectation and it limited the possibility
of much collaboration (Rice et al, 2010).
Nursing should acknowledge that it, too, has been
guilty of elitism and of exhibiting professional dominance
and defensiveness, both in relating to other nurses with
different levels of education and expertise and in working
with other health-care professionals. Lack of understanding, failure to acknowledge roles and responsibilities of
other professionals, and the very isolated nature of health
professional education is the basis for much of the elitism
still prevalent today (Glasgow, Dunphy, & Mainous, 2010;
Rice et al, 2010).
Organizational Hierarchy
The key to the inadequacy of health services is described
as professional dominance, a situation in which health
services revolve around professional authority, with a
foundational structure of dominance by a single profession

130 Unit 2 The Practice Environment
more intensity to the conflicts among health professionals
regarding SOP and Gardner emphasizes that the most
visible interdisciplinary fight is over SOP expansion,
noting that until there is an expansion of SOP, APNs
in many states will not be able to provide services to
the fullest extent of their training and knowledge, skills
and experiences (Gardner, 2010, p. 264). Gardner
then notes that disputes are not only interest-based, but
values-based and professional identity-based as well.
Identity conflicts seem to relate to a professionals need
to be treated with deference or ones difficulty in compromise; value-based conflicts arise when values relating
to one professional culture differ from the other, such as
in lines of communication being unidirectional; conflicts
of interest seem to infer that one professional should get
more (money, prestige, patient say) at the expense of the
other. The challenge is to somehow address these issues
using strategies such as mediation, clarifying SOP and
interprofessional education.
Expanding Scopes of Practice
Nursing SOP is the extent of clinical actions, decision
making, and patient management responsibilities authorized by state and federal law (i.e., the legal base
of practice). However, SOP evolves and changes over
time as variables change: nursing education, state and
federal laws, professional standards and guidelines,
policies of the workplace, experience of the nurse,
changing needs of the community, expanding SOPs of
other health professionals (such as pharmacists), and
emerging models of health-care delivery that expand
the role of nonhealth-care professionals. Schuiling and
Slager (2000) described this as freedom with limits
noting that determining ones SOP requires the health
professional to first review the inflexible boundaries
set down by professional standards of practice and core
competencies and then examine the clinical reality and
extent of his or her practice, considering the practice
setting, education, years of experience, nature of collaborative relationships, and needs of the community.
This latter is the flexible grey area that helps to better
define and potentially change the inflexible current
legal parameters of practice. Although the IOMs report
(2011) on the future of nursing supported expansion of
nursings SOP and the ACA of 2010 opened the way for
no longer the essence of nursing but becomes medically
directed care delivered by nurses (p. 30). Supervised or
medically directed care seems to fall within the framework
of multidisciplinary interactions representing a very limited level of intensity of relationships and collaboration.
Supervision may not preclude some level of collaboration,
but it seems to severely limit its scope. The extent of
collaboration possible within such a delegated mindset
is questionable.
Unrecognized Diversity
Diversity in a health-care team can have a powerful impact
on its success or failure as a cohesive workgroup. It can
bring a wealth of helpful differences but can also be the
cause of great conflict within the group. Cultural diversity
may be easily recognized and acknowledged, but there
are many complex aspects of diversity that may not be
recognized and that can undermine team efforts. Three
major categories of diversity are informational, social category, and value (Jehn et al, 1999). Informational diversity
reflects the differences in knowledge and perspectives of
team members flowing from their education, experiences,
and levels of expertise. Social category diversity relates
to age, race, gender, and ethnicity and is the aspect with
which we are most familiar as cultural diversity. Value
diversity reflects the differences in members perspectives
of the mission, goals, and values relating to the work at
hand. A study of the impact of diversity on work-group
performance found that different forms of diversity could
result in different levels of performance within the team.
Having high information diversity (differences in education and experience) can make a team quite effective
because of the many professional perspectives that can be
available to the team. However, if it is accompanied by
high value diversity, the team may malfunction as a unit.
Over time, age, gender, and race differences in a group
become less important, but value diversitydifferences
in understanding of the mission, goals, and values
becomes the more important component as a predictor of
conflict or success. The complexity of relationships within
a team is heightened by the level and type of diversity.
Often unrecognized or unacknowledged, value diversity
may be the most critical factor in the success or failure
of teamwork and collaboration (Jehn et al, 1999). The
implementation of the PPACA seems to have brought

Chapter 8 The Kaleidoscope of Collaborative Practice 131
what level or type provider; and (c) how well the attributes of primary care are achieved by nonphysicians in
comparison with care by physicians. Concerns raised
by Starfields discussion of the primary care center were
related to the language used, as well as her consistent
adherence to the traditional medical viewpoint of the
physician as the captain of the ship. The use of the
term team is quite perfunctory and seems to imply only
a multidisciplinary collection of individuals gathered
by the physician to facilitate his or her practice. The
three functional typessupplementary, substitutive,
and complementaryare each defined in relation to its
ability to enhance physician effectiveness rather than
as shared components of a joint practice. In addition,
Starfield (1992a) frames the role of the nonphysician
provider by tasks and functions, severely limiting the
scope of advanced practice and the role of collaboration.
Collaboration, often used in statute, is frequently
interpreted in rules and regulations as supervision, implying a hierarchical relationship and a contradiction to
the critical indicators of collaboration. For collaboration
to consistently mean an egalitarian, collegial relationship,
the legislative language must be more clearly defined. The
question becomes whether power sharing can coexist with a
supervision requirement in a practice. When collaboration
is mandated, or termed supervision, the process of shared
practice becomes one of forced negotiation in which the
dominant profession, medicine, has the choice of collaboration, with no legal need for a collaborative partner,
whereas the subjected profession, nursing, must obtain
a collaborative partner to legally function within the full
scope of its practice (Sullivan, Morgan, Heimerichs, &
Scott, 1998). Physician involvement can be termed collaboration, supervision, direction, delegation, or authorization, and the meaning of each term can be ambiguous,
particularly in statute.
Statutory requirements for collaboration for advanced
practice nursing couched as delegated or supervised
practice are not acceptablefor several time-tested reasons. If
patterns of practice arelegislated, legislativejudgment becomes
limited by the parameters of thelegal definitions, rules, and
regulations of thestatein which the practiceis located. The
flexibility needed for individual clinical situations may be
seriously compromised by theselegally defined parameters.
The result is that, because of restrictive legislation, rules,
regulations, and reimbursement policies, advanced nursing
new models of care using nurses in expanding roles, the
ability for APRNs to practice to the full extent of their
education and expertise continues to rest in the hands of
state legislators (Marshall, 2016). Nurses must continue
to provide education to other health professionals and
the public regarding the realities of their education
and expertise. Clarity of SOP is key to team building
and collaboration among practitioners and for full
implementation of the nurses practice potential.
Role and Language Confusion
The increasingly expanding scope of nursing practice
being experienced across the United States continues to
be hampered by inconsistencies of legal language and
titling variations among states. Additional challenges
to the clarity of health provider roles and SOP are also
being experienced as pharmacists seek to provide patient
education as well as independent prescriptive privileges
and provision of immunizations in local pharmacies and
CNMs seek legislative approval to provide primary care
(Keely, 2002; Phillippi & Barger, 2015). In examining the
role of primary care provider, Starfield (1992b) identified three types of functions performed by nonphysician
personnel: (a) supplementary, extending the efficiency of
the physician by assuming the technical tasks, usually
under the direction of the physician; (b) substitutive,
providing services usually provided by physicians; and
(c) complementary, extending the effectiveness of physicians
by doing things physicians do not do at all, do poorly,
or do reluctantly. Noting that the nonphysician role has
not been clarified to the extent that the three functions
can be differentiated, Starfield concluded that primary
care is largely a physician-dominated effort. Although
primary care cannot function without some teamwork
involving other practitioner providers, she believed that
there was little evidence supporting the concept of team
practice and little research indicating when and under
what conditions a team approach may be more effective
than a singular practice approach. In conclusion,
Starfield asserted that primary care should be provided
by physicians and the concept of teamwork in primary
care needed to be researched regarding (a) standards for
different roles and relationships; (b) identification of which
type of delegated functionsubstitutive, supplementary,
or complementaryis most appropriately assumed by

132 Unit 2 The Practice Environment
requirements on nurse practitioners for physician collaboration, direction, or supervision, reflecting a movement
toward the autonomous nursing role and facilitating a
teamwork approach to practice.
Another language issue relates to the use of protocols
and clinical guidelines. Protocols are defined as the detailed
plan of a scientific or medical experiment, treatment, or
procedure (Merriam-Websters, 1994). In research, they need
to be followed to the letter to have accurate, consistent,
and comparable sets of data. The concern with protocols
comes with their use in statutes, rules, and regulations as
a definitive set of boundaries restricting practice to sets of
predetermined criteria. When the perception of nursing
is a dependent practice under physician supervision, the
mechanisms created for allowing advanced practice often
include a system of protocols designed with the approval
of the collaborating physician. However, this solution
compromises the concept of nursing autonomy, suggests that
the nurse is incapable of making accurate choices among
treatment options, and becomes implicit standing orders
reinforcing nursing dependency (Baer, 1993). In somestates,
neither protocols nor a collaborative practice agreement
with a physician is required for full practice privileges. In
others, if prescriptive authority is possible, a collaborative
practice agreement with a physician may be required,
but perhaps no protocols. Historically, clinical guidelines
represented collective wisdom gathered over time and were
considered no threat to autonomy. In contrast, guidelines
today may not be as willingly accepted because of the fear
that they might influence or manage provider behavior.
If guidelines or protocols allow room for the exercise of
provider judgment, they will support provider autonomy
as well. The Agency for Healthcare Research and Quality
(AHRQ) uses theterm clinical practice guidelines to describe
systematically developed statements to assist practitioner
and patient decisions about appropriate health care for
specific clinical conditions. They may be broad or very
detailed based on literaturereview as well asexpert opinion.
These are written by independent multidisciplinary panels
of private-sector clinicians and otherexperts supported by
AHRQ. Practitioners must have clinical guidelines in place
for reimbursement from Medicare (Newman, 1996), and
they are viewed sometimes as an excellent tool for communicating theroleto funding agencies (Way & Jones, 1994).
One additional aspect of language confusion is that
of titling of APRNs. Many titles found in the different
practicetoo often depends on the willingness of a physician
collaborator, whereas thesamelimitations are not placed on
the physician. One can only imagine what thereaction of
organized medicine would beif a statelegislature attempted
to delineate when and how internist physicians should refer
patients to a specialist (ANA, 1998, p. 4). Legislatively
mandated collaboration often results in a conflict (Sullivan,
1998). In states where APRN practiceis controlled by joint
board decisions, the negotiation process of joint rule making
can become very hostile because of an unequal balance of
power among the parties. Further, when membership of the
board of nursing includes representatives of each level of
nursing, those members not in advanced practice may lack
the knowledge baserequired for debating advanced practice
issues such as prescriptive authority. The subsequent rules
passed may befar morerestrictivethan had been imagined
from the broader language of the statute. Reasons offered
by Sullivan and colleagues (1998) for the failure of these
disparate groups to accomplish an externally imposed
power-sharing partnership are not difficult to understand.
They state (p. 350),
Because the participants did not share a common purpose or
vision, and were forced to meet, it is not surprising that they
did not work well together or achieve a satisfactory resultby
any standards. Becausethe representatives wereforced to come
together and their Boards had their budgets held hostage to
the process, it was not unexpected that despite the need to
reach some level of agreement there was little commitment
to a win-win situation. . . . Instead, representatives of each
discipline worked to protect their distinctly different professional agendas. It became not a collaborative process but
a legalistic and formalized process of enforced negotiation.
Collaboration has also been described as an interdependent, interdisciplinary practice in which the APRN role
is substitutive in a primary care setting in contrast to
the complementary role more applicable to acute-care
settings (King, Parrinello, & Baggs, 1996). However,
there are difficulties with the use of the term substitutive
because it implies a temporary stopgap until the regular
practitioner can be provided. More contemporary views of
collaboration and interdisciplinary practice steer clear of
the substitutive and complementary language and stress
partnership and the unique areas of expertise of each
member of the team (Donald et al, 2009; IOM, 2011).
In a 2015 report, the Kaiser Family Foundation notes that
33 states no longer impose any statutory or regulatory

Chapter 8 The Kaleidoscope of Collaborative Practice 133
lead to a misconception of the nurse role. No nurse can
assume the role of a physician, nor can a physician assume
the role of a nurse. What is possible is that certain responsibilities, functions, and skills are learned and assumed
by both providers. When the nurse assumes some of the
responsibilities, functions, and skills traditionally assumed
by the physician, if they fall within the scope of nursing
practice, they are nursing. If they fall outside, they are
considered medically directed acts, and the nurse in that
instance is serving as assistant to the physician. It follows,
then, that if a physician assumes some of the responsibilities, functions, and skills traditionally assumed by the
nurse, they would be considered nurse-directed acts and
the physician is serving as assistant to the nurse.
Inadequate and Inappropriate
Communication Patterns
When physicians and nurses do not share information or
concerns, when communication is a one-way street, or
when there is an inadequate system of written and verbal
communication, quality of patient care suffers. Poor
communication patterns also affect working relationships
and seriously hinder any attempts at collaboration, often
resulting in separate professional decision making that
can create confusion and safety issues (Clarin, 2007;
Zwarenstein & Bryant, 2000). Inappropriate communication patterns may reflect a pattern of physician abuse.
In a survey of nursephysician relationships (Rosenstein,
2002), the level of respect for nurse input and collaboration
was rated significantly higher by physicians than by nurses.
However, physicians rated the findings on how important
the physicians disruptive behavior was in contributing to
nurse dissatisfaction and low morale much lower than nurses
did. These findings reflect a dissonance in perception that
is often a result of poor communication and lack of trust,
creating a defensive, noncollaborative practiceenvironment
in which the number of errors rises and patient safety and
positive patient outcomes are threatened. Magnet hospitals,
emphasizing collaboration between physicians and nurses,
have been documented as having better patient outcomes
and fewer problems relating to shortages, turnover, or
abuse (Drenkard, 2010; Fischman, 2002).
Another aspect to consider is the line of reporting
accountability. An NP-staffed fast track in the ED of
Vanderbilt University Medical Center was designed using
state statutes include advanced nurse practitioner (ANP),
advanced practice nurse(APN), advanced practice professional nurse (APPN), advanced practice registered nurse
(APRN), advanced registered nurse practitioner (ARNP),
certified nurse practitioner (CNP), and registered nurse
practitioner (RNP). The APRN Consensus Model for APRN
RegulationLicensure, Accreditation, Certification, and
Education (LACE)defines advanced practice and each
specialty, describes the regulatory model, and identifies
titles to be used. This document was created by regulators,
nurse educators, APRN certifiers, and representatives of
a large number of APRN professional organizations with
the goal of creating national consistency regarding laws
and rules regulating APRN practice. With some physician
groups still insisting on supervision, the challengeremains
to get past thelanguage barriers and clarify roles to foster a
collaborative approach to care. The Pearson Report (2011)
encourages NPs to sharethe updated legislativeinformation
with their legislators to help them understand that NPs
are competent and high-quality clinicians and to remove
barriers to advanced practice nursing.
The launching of doctorate of nurse practice (DNP)
programs has also created some language difficulties. The
fairly recent nursing doctorate (ND) has been phased out
and the DNP is now identified as the future expectation
for all APRNs. One expected benefit of the DNP is the
greater opportunity to fully participate on the interdisciplinary team. However, there are challenges to the concept
suggesting that the educational and clinical residency requirements of the DNP do not prepare one for becoming
faculty, assuming leadership roles, or conducting clinical
research (Brar, Boschma, & McCuaig, 2010; Webber,
2008). In addition, the term Dr. Nurse is causing many
physician groups to challenge not only the terminology
but also the concept itself (Landro, 2008). In some states,
legislation has directly challenged the nurses ability to
be called Doctor despite having doctoral credentials,
simply because they are not physicians. A report of
a developing collaborative practice in the emergency
department (ED) stated, By performing the dual role of
physician and nurse, the NP eliminates the fragmentation
of care often seen in the ED where patients see many
different physicians, nurses, and staff members and there
is no consistent provider (Covington, Erwin, & Sellers,
1992, p. 124). Instances in which the APRN is described
as assuming the dual role of physician and nurse can

134 Unit 2 The Practice Environment
than the nurse, indicating a lack of mutual power control.
In another study examining provider concerns, nurses and
physicians wererated on the degreeto which they achieved
both assertiveness and cooperativeness, with high levels of
both dimensions indicating collaboration. Nearly half of the
responses reflected competition, compromise, or accommodation as the preferred method of safeguarding concerns.
They did not agree on where responsibility for practice
should restnurse, physician, or bothand they agreed
on only 4 of 24 practice goals (e.g., maintain elimination
patterns, promote cardiovascular healing). The conclusion
reached was that nurses and physicians who cannot agree
on provider responsibility regarding areas of practice and
patient goals reflect a lower level of collaboration and will
not be able to deliver the same high level of coordinated
patient care as those nursephysician teams who agree on
the areas of responsibility (Norsen et al, 1995).
The Bottom Line
Barriers to collaboration hinder positive change and growth
in our health-caresystem but do not need to be perpetuated.
Organizational climate and culture are living, growing
aspects of institutional work lifethat bind the organization
together. Professions and professionals are not static. They
can and must work to eliminate barriers to collaboration
and create a new culture of team practice in health care.
Collaboration is a developmental process that emerges
slowly through a series of sensitive and delicate interactions.
Members of a newly forged partnership join forces in the
belief that the common need they recognize can best be
met through their combined efforts. Levels of collaboration
achieved depend on context, ability, and the desire of the
prospective partners to skillfully develop the practice. Based
on the conceptual framework of collaboration described
in this chapter, the following are some key strategies for
developing a successful collaborative team.
Create a Collegial Team
Teamwork is a critical need for today and the reality
of tomorrows practice. Peters and Waterman (1982),
written protocols created collaboratively by the NPs and
the medical director of the ED. Although the NPs reported
to the ED nursing director and the physicians to the
ED medical director, the collaborating practice was well
established within a few months with a growing sense of
confidence and trust between these distinct professional
providers. However, the report made no mention of the
effect of a parallel reporting system (Covington, Erwin, &
Sellers, 1992). If reporting is different foreach practitioner,
does that negatively affect the practice?
Professional Dissonance
When diversity is not recognized and acknowledged, the
result is professional dissonance with a serious negative
impact on the capacity for teamwork. Confusion of
language, differing communication patterns and ways of
interacting, and difficulty respecting each others skills and
roles are inevitable. In a study of attitudes regarding teamwork by critical care nurses and physicians, a seven-item
teamwork climate scale was developed. It found that
nurses and physicians had distinctly different attitudes
toward teamwork. The source of the differences was found
to be status or authority, responsibilities, gender, training,
and professional culture (Thomas, Sexton, & Helmreich,
2003). In a study of nurses and physicians in a medical
intensive care unit (ICU), Baggs and Schmitt (1997) found
that collaboration would occur only if the time and place
were appropriate, the physician believed the nurse had the
knowledge needed, and trust, respect, and sincere interest
in teamwork were present. For example, the physicians
believed the general medical unit nurses did not have
the same level of knowledge about medical illness as the
medical ICU nurses. This perceived knowledge level was
a precondition to the physicians willingness to collaborate
more effectively with the nurses in the ICU.
A study by Jones (1994) explored the nature of nurse
physician collaboration, examining the differences and
similarities in their perceptions related to thefour indicators
of nursephysician collaboration identified in the ANA social
policy statement of 1980: mutual power control, mutual
safeguarding of provider concerns, responsibility for practice,
and practice goals. The findings offer an interesting portrait of
the collaborative perspective of the partners. Although nurses
and physicians were in agreement on power control, most
affirmed that the physician initiated more communications

Chapter 8 The Kaleidoscope of Collaborative Practice 135
because it could freeze them into rigid adherence to
outdated approaches to care.
3. Shared vision. Shared vision is described by Senge(1994)
as the first step in allowing people who mistrusted each
other to begin to work together as it creates a common
identity and sense of purpose (p. 208).
4. Team learning. Nurses, physicians, and others on the
team learn to think together about complex issues,
acknowledging that the whole is truly greater than
any of the individuals. They develop what is termed
operational trust and master the practice of both dialogue and discussion. The apex of team is at the
transdisciplinary level.
5. Systems thinking. Foundational in teamwork, systems
thinking forces a focus on the whole pattern of the
collaborative practice rather than any isolated role.
The structure or key interrelationships of the practice
pattern influence behavior and decision making and
are examined collectively.
Accept Growth and Development
as a Joint Responsibility
For the concept of collaborative practice to grow and
flourish, interdisciplinary education must be supported,
affirming the values and roles of both physician and
nurse. Educational institutions must reaffirm the value
of education for interdisciplinary practice and implement the results of studies of the effect of collaboration
on clinical outcomes. In practice, bidirectional referrals
must be promoted and must include the expanded APRN
SOP and skill set found in the APRN role description.
Professionals and the public must be educated regarding
the roles by both physician and nurse partners. Strategies
recommended for physicians to address physician abuse
and improve collaboration include physician education,
zero tolerance policies, role playing, and changing the
culture of the environment from defensive and hierarchical to supportive and collegial. Nurse responsibility for
the problemin tolerating the behavior, perpetuating
the inequalities in the nursephysician relationship,
and sometimes countering with abusivenessshould be
addressed with education, role playing, assumption of
accountability, and an assertive capability to share the
nursing perspective (Buerhaus, 2010; Fischman, 2002;
Glasgow, Dunphy, & Mainous, 2010).
focusing on people as the means to achieve productivity,
suggested that coworkers should be treated as partners.
The reality of this shift of power from an authoritarian
command structure to one of collegial teamwork can result
in innovation, rapid response, and greater access by the
customer. However, it requires a considerable mind shift by
participants. The redesign of a health-care delivery model
that supports a collegial, interdisciplinary team approach
requires a radical way of thinking to acknowledge that
this new model is not something out there, but belongs
to each of the participants as they confront their learned
beliefs and perspectives. In addition, the participants
must realize that they must undergo a significant cultural
shift in accepting that they must become a community of
learners, a learning organization that never arrives but
continues to translate a shared vision into an ever-evolving
practice (OBrien, Martin, Heyworth, & Meyer, 2009;
Rice et al, 2010; Senge, 1994). The key feature of this
type of learning organization is a realization that the role
of the grand strategist at the top is no longer possible
because of the complexity and dynamic status of work.
Instead, each individual participants commitment and
capacity to learn is tapped. Unlike a linear approach,
the learning organization forges ahead based on shared
understandings of interrelationships and patterns of
change, thereby creating a common bond of commitment
to the practice.
One approach to initiating dialogue to address professional conflicts of values, professional identity, and interests
is through mediation. Gardner (2010) suggests that the
mediator challenge key medical and nursing professionals
to acknowledge their core values, to facilitate discussions
in which each side accepts those aspects of the others values that it can agree with, and then build on those shared
beliefs (p. 266). In summary, five qualities are suggested
as essential for participants in the learning organization
that never arrives but continues to translate a shared
vision into an ever-evolving practice (OBrien, Martin,
Heyworth, & Meyer, 2009; Riceet al, 2010; Senge, 1994):
1. Personal mastery. The practitioner is true to a personal
vision while staying committed to the truth of the
current reality.
2. Use of mental models. Learning is accelerated as we
mentally consider alternativescenarios for care delivery.
Participants do not become so attached to one scenario

136 Unit 2 The Practice Environment
for APRNs through legislative or regulatory changes in
2009, compared with 22 in 2008 and 19 in 2007. In
2015, three states completely eliminated collaborative
and supervisory models of practice This brought the total
to 22 states plus the District of Columbia (DC) that
now allow for full NP SOP, meaning no collaborative
agreements with a physician are required. However,
28 states still require some sort of agreement for prescribing and advanced clinical practice, underlining a need
to continue to work to remove barriers to full SOP for
APRNs (Phillips, 2016). The annual legislative reports
of Phillips (2016) provide a benchmark and an incentive
for regulatory reform and language clarity; however,
practitioners must be careful to not eliminate a sense
of collaboration as they move to eliminate restrictive
collaborative agreement requirements.
Watch Your Language
Language is one of the most significant facets of relationships. In an editorial from American Family Physician
(Phillips et al, 2001), a physician professor took aim at the
use of the term health-care provider, noting that calling
me a provider lumps my physician colleagues and me
with individuals who are frankly less qualified and yet
aspire to do the same work we do . . . the use of terms . . .
although politically correct diminish us as professionals
(p. 1342). That same year an article in the Annual Review
of Medicine (Cooper, 2001) was titled Health Care
Workforce for the Twenty-First Century: The Impact of
Nonphysician Clinicians. No APRN I have ever known
has positively embraced the concept of his or her practice
as being that of a nonphysician clinician. In a forecast
study of Missouri nursing (Kuehn & Porter, 1993), the
first round of the Delphi brought together both nurse and
nonnurse participants. One physician commented that
it was the first time he had ever been called a nonnurse
and found it rather demeaning. When he was reminded
of the nurse correlative being termed a nonphysician, a
shared understanding of the awkwardness of either term
in supporting a sense of collegiality emerged. In stark
contrast to Starfields (1992b) language of dependency
flowing from delegated medical functions, nursing
language stresses the need to avoid definition by function
or tasks when describing role. Orem (1995) stresses that
a task orientation for nursing disallows the focus on the
Use Protocols and Guidelines Wisely
In clinical practice, protocol is often used synonymously
with clinical guidelines and is representative of a statement of agreement between an APRN and his or her
collaborating physician. When the providers agree on
a standard of care acceptable to both, the guidelines
or protocols stand as their codification of acceptable
criteria for diagnosing and managing an illness or condition. Classic texts such as Patient Care Guidelines for
Nurse Practitioners (Hoole, Pickard, Ouimette, Lohr, &
Powell, 1999) and Gerontological Protocols for Nurse
Practitioners (Brown, Bedford, & White, 1999) offer
excellent resources for practitioners, as well as sometimes
serving as the basis for legal documentation to allow for
treatment and prescriptive privileges through incorporation into the collaborative agreement as the agreed-to
standard of care. More current articles on development
of clinical protocols are increasingly available such as one
by Martinen and Freundl (2004) describing the development of an interdisciplinary protocol for managing
congestive heart failure in long-term care and another
by Colon-Emeric et al (2007) identifying Barriers to
and Facilitators of Clinical Practice Guideline Use in
Nursing Homes.
Clinical practice guideline development needs three
aspects to accomplish its goal. First, identification of key
decisions and their consequences must be outlined. In
the case of the APRN, there are decisions to be made
about when to call the physician with questions and
when referral to an outside specialist is in order. The
process of reviewing charts and prescriptions is the
second aspect. Finally, reimbursement from insurance
providers must be defined because of strict insurance
policies and legislative mandates. Although state and
federal statutes may allow for certain billing practices,
the viability of the practice may be hampered when
nurse professionals are limited to lesser reimbursement
amounts or are refused reimbursement. Legislative language in many states must continue to be reworked to
clarify the meaning of the terminology, role and scope
allowed, and the effect on practice viability of protocols
and clinical guidelines. Progress is ongoing regarding
legislative and statutory language changes needed for
clarification and full SOP. The Pearson Report of 2011
noted there were 31 states reporting an expanded SOP

Chapter 8 The Kaleidoscope of Collaborative Practice 137
design and/or subsidy of programs providing incentives for
health professionals to choose specialties and practice location.
Socialize Students to Communication Skills
Needed for Collaborative Interactions
When education includes the process of establishing
an interdisciplinary team, it helps to create a system for
promoting collaborative practice and facilitates the use of
essential communication skills. One point highly stressed is
theinsistencethat interdisciplinary teams should be already
delivering care and have a solidly positive practice in place
before integrating students into the teams (Hanson &
Spross, 1996; Hughes, 2011; Norsen et al, 1995). Alberto
and Herth (2009) explored in depth the history, benefits,
and challenges of interprofessional collaboration in education and practice, offering an excellent review of their
experiences with collaboration in health-care education.
Examples of interdisciplinary professional education initiatives may be seen in Table 8.2. Group dynamics, role
theory, organization theory, change theory, negotiation
strategies, team interactions, networking, and focus on
the need for organizational leadership for supporting
interdisciplinary programs are key factors in these interdisciplinary educational initiatives preparing students and
enabling practitioners to function in a collaborative world.
pioneers and Emerging models
For clarity, many of these models are described as they
wereimplemented with specific populations and in specific
settings. However, they are transferable to a variety of
places where health care is practiced once the philosophy
and concepts are extracted and understood.
Early Pioneers
Primary Nursing Model
A national project conducted by the National Joint Practice
Commission (NJPC, 1981) required hospitals utilizing
a primary nursing model of practice to demonstrate
100% registered nurse staffing, individual clinical decision
making by the registered primary nurse, a joint practice
person. To define oneself as a nurse, the following questions must be answered:
What do I do (scope of practice)?
How do I do it (methods of practice, tasks)?
Whom do I care for?
Why do they need or want my care?
The ANA social policy statement of 2015 reaffirmed collaboration as a standard of practice. Although advanced
practice nursing texts have consistently addressed the
concept of collaborative practice, undergraduate nursing
texts on professional practice have not historically addressed collaboration. Often the word is not even found
in the index, and if it is, it has nearly always referred to
collaboration between nursing practice and education or
between types of nurses within the same setting. However,
this too is changing. A chapter in the 2002 text Professional
Nursing Practice, The Nurse as Colleague and Collaborator, noted, changing models of health care have created
a need for modification of traditional roles. Nurses and
physicians have been especially affected by these changes
and work more collaboratively (Blais et al, 2002, p. 199).
In a spring 2001 report, The Health Care Workforce
in Ten States: Education, Practice and Policy (American
Federation ofTeachers [AFT] Healthcare, 2001), 10 pilot
states were studied regarding the status of their health-care
workforce. Aspects compared were data collection status
and process, practice issues, influences, and policies. In
describing licensure and regulation of practice, the extent
of physician supervision varied considerably among states
and among types of providers. In one state, APRN practice
called for both independent judgment and collaborative
interaction with other health-care professionals. However,
neither collaborative interaction nor other health-care
professionals was defined in their practice act (AFT Healthcare, 2001, p. 50). Although the effect of the enforced
collaboration and supervision on APRN practice (noted
in 9 of 10 states studied) was not addressed, researchers
(AFT Healthcare, 2001, p. 2) affirmed that
the greatest opportunities for influencing the various environments affecting the health workforce lie within state
governments. States are the key actors in shaping these
environments as they finance and govern health profession
education; license and regulate health profession practice and
health insurance; purchase service; pay designated providers
under Medicaid programs; and often assumeresponsibility for

138 Unit 2 The Practice Environment
have (Devereux, 1981; Sullivan, 1998). The results from
the four participating hospitals were positive in relation
to improved doctornurse communications, increased
mutual respect and trust between physicians and nurses,
increased job satisfaction for physicians and nurses, and
highly satisfied patients.
Differentiated Practice Model
In recent years, the cost effectiveness of the primary nurse
model has been challenged based on the limited reality of
achieving it amidst a nursing shortage. However, newly
developing models of differentiated practice have converted
the primary nurse concept into that of a patient care
coordinator (PCC) who assumes 24-hour accountability
for specific patients. The PCC, however, does not deliver
all the care personally. Instead, a team of other nurses and
ancillary help assume major responsibility for care delivery,
committee with equal representation of providers, an
integrated patient record, and joint evaluation of patient
care. The structural elements of integrated records, joint
practice committees, and joint care review reflect the
common goals, mutual concerns, and shared control
identified as critical indicators of a high-level collaborative
practice (see Table 8.1). Primary nursing, the performance of clinical nursing functions by registered nurses
with minimal or no delegation of nursing tasks to others
(NJPC, 1981, p. 11), is considered essential for enabling
the nurse to better enter into a collegial relationship with
the physician. The emphasis on the primary nurse role,
coupled with the element of increased nurse responsibility
for decision making, relates accountability directly with
collegiality and individual clinical decision making by
nurses and is considered to be a prerequisite for shared
decision makingyou cannot share what you do not
Table 8.2
Interdisciplinary Professional Education Initiatives
Project or Model Location or Clinical Area Focus Citation
Interdisciplinary Educational
Vanderbilt University Medical, APRN, pharmacy,
and social work students
learning together
Buerhaus, 2010
Simulation training Freestanding childrens
hospital in the southeastern
United States with teams
consisting of pediatric
residents and fellows and
nurse volunteers
A study to determine the
level of physiciannurse
collaboration in pediatrics
using simulation exercises
Messmer, 2008
Proposed transdisciplinary
medical, nursing, and
health professional
simulation center
Multiple examples of models
being tested in various
clinical areas, nationally
and abroad
Students from the health
disciplines, nursing, health
professions, and medicine
who are exposed to the
complexities of teamwork
within a clinical setting
Glasgow, Dunphy, &
Mainous, 2010
Continuing education in
classroom and clinical
Baystate Health of
Strengthening collegial
Trossman, 2014
Simulation labs University of Alabama,
Strengthening collegial
Trossman, 2014
Annual emergency
department skills blitz
simulation exercises
Cone Health of Greensboro,
North Carolina
Strengthening collegial
Trossman, 2014

Chapter 8 The Kaleidoscope of Collaborative Practice 139
process of this collaborative practice model can serve as
an excellent template for clinics and provides additional
proof of the value of interprofessional collaboration.
Building on this concept, the Nurse-Managed Health
Clinics (NMHCs) were established by the PPACA to serve
underserved populations. This grant program requires
the clinics to be led by APNs who are associated with a
school, college, university or department of nursing, a
federally qualified health center, social services agency,
or independent nonprofit health agency (Haney, 2010).
Collaboration in Long-Term Care
For more than 30 years, collaborative practice models have
been developing in long-term care (LTC). Collaborative
models in LTC as described by the AMDA (formerly the
American Medical Directors Association) Ad Hoc Work
Group (2011) include differentemployment scenarios, such
as the APRN employed by the physician, self-employed, or
employed by the nursing home; a specialty APRN collaborating with a specialty physician; and the care manager.
The positive impact of NPphysician partnerships in
LTC has been reported in studies of the Nursing Home
Demonstration Project and the Teaching Nursing Home
Project, among others. In the 1980s, two NPs developed the
LTC model of care teams that focused on coordinated care
of frail and elderly nursing home residents (Kappas-Larson,
2008). They founded the Evercare Company, whosefacilities
are now nationwide and whose model is used both in nursing homes and in the community where nursephysician
teams care for seniors who are still living independently
at home. Seven specific practice roles of Evercare NPs are
collaborator, clinician, care manager or coordinator, coach
or educator, counselor, communicator, and cheerleader.
The NPs serve as the center of the interprofessional
care team in which both physician and nurse are valued
partners. It is required by Evercare that each NP establish a positive relationship with his or her collaborating
physician. As physicians become more aware of and comfortable with the NPs skill and expertise, they grow more
supportive of the role. Active participation by physicians
in LTC patient care is reported higher in Evercare programs, perhaps because their increasing comfort in LTC
care participation is caused by their confidence in their
NP partner. Physicians have said that one of the most
important components of their experience with Evercare
is the personalized and coordinated care patients receive,
each with specific roles and levels of accountability. Each
nurse is paired with certain physicians and his or her
patients, and trust and collaboration are more readily
developed as nurse and physician work together. This
collaborative system model of patient care delivery has
reported higher levels of coordination, cost effectiveness,
and patient and provider satisfaction than previously seen
in less collaborative models (Devaney, Kuehn, & Jones,
2002; Koerner & Karpiuk, 1994).
Collaborative Practice Model in a Clinic Setting
A collaborative practice model established in the early
part of 2000 in an inner-city clinic in Beirut, Lebanon,
reported a positive impact on quality of care of patients
with type 2 diabetes mellitus that was nothing less than
amazing (Arevian, 2005). The researchers first identified
four key elements essential for the modelcollaborative
defining of the problems; joint goal setting and planning; providing a continuum of self-management and
support services; and maintaining active and sustained
follow-up (p. 446). In developing the model, they determined that thorough preparation of the professional
team members would be an essential factor for success.
In addition, they developed provider support systems,
including standardized guidelines for care management;
provided for patient education in illness management
skills; and provided consistent access to a single team
member. The development process was proven to be
very effective because teams reported a high level of
enthusiasm, cooperation, willingness to share expertise,
and acknowledgment of skills of other colleagues. As
one physician said, We were treating each other like
colleagues, with mutually respectful relationships, and
another noted that he gained insights into how much
and how well the other team members contributed to
patient care (p. 449). Outcomes reported included
improved documentation, increased patient recruitment,
and improved glycemic control, as well as decreased cost
of care. The most amazing aspect of the clinic was the
positive response of team members to each others skills
and expertise in a Middle Eastern culture in which nurses
are still considered as handmaidens to physicians. In
addition, the positive patient response to active participation in their care was surprising in a Lebanese culture
that encourages passive submission to the physician
authority figure (Arevian, 2005, p. 450). The development

140 Unit 2 The Practice Environment
are a facet of Medicares cost-saving plan and members
share in any bonuses received from meeting cost saving
targets. The ACOs allow for greater nursing leadership
and participation; however, CNMs and CRNAs are not
included as practitioner participants at this writing. In
addition, pilot projects are working on testing the model
with both Medicaid and private payers. Key benefits for
nursing include leadership and increased collaborative
opportunities (Haney, 2010).
Medical/Health Homes
The Patient-Centered Medical Home (PCMH) model
is a move away from the traditional primary care model
as it seeks to provide coordinated care through an interprofessional team of health-care providers. The concept
of a medical home is not new; it was introduced in 1967
by the American Academy of Pediatrics to better serve
children with special health-care needs. The PPACA has
served as an impetus for newly emerging community-based
interdisciplinary and interprofessional teams. These
teams must include physicians; have a patient-centered,
whole person orientation; and provide a broad scope of
coordinated-care services, expanded access, and provide
quality, cost-effective, and culturally appropriate care
across the age spectrum. These aspects aim to increase
patient positive outcomes; reduce repeat hospitalizations;
and promote effective, personalized, and timely access
to care. Emerging models and pilot projects stress care
coordination as the key to success to the medical home
concept and offers nursing an excellent leadership opportunity for preparing teams to deliver patient-centered
care, a core aspect of nursing practice (Schram, 2010;
Swartwout et al, 2014).
Emerging Model of Shared
Decision Making
SDM is a collaborative model of health-care delivery in
which patients actively participate in treatment decisions.
The model places the nurse in a key role as patienteducator,
advocate, and facilitator of the exchange of information
between patient and the health-care team as they work
together to find a mutually acceptabletreatment plan among
patient, physician, nurses, and other providers. McCarter
et al (2016) describes this model as the dominant delivery
model in cancer nursing practice.
thanks in part to the quality of Evercares NPs and care
managers (Kappas-Larson, 2008, p. 135).
Collaboration in LTC facilities should include other
employees who are involved in patient care. For example,
a recent educational program about heart failure for certified nursing assistants (CNAs) in a LTC facility designed
and led by a NP focused on CNA clinical education and
CNAnurse communication, especially in regard to not
only recognizing but reporting vital resident information
in a timely manner. It was stressed that the CNA be included in all quality improvement projects to promote
CNA input and maximize buy-in (Kim, Ea, Parish, &
Levin, 2016, p. 34).
Emerging Models of Shared
Professional Practice
Shared Governance
Shared governance is a collaborative organizational model
in which management and staff acknowledge that their
interdependence and power is balanced equally on issues
relating to nursing practice (Porter-OGrady, 1992). A
recent model of shared governance on an oncology unit
is focused on collaboration and mutually agreed on goals
between the CNS and the nurse manager. It is described
as an approach focusing on professional development,
shared decision making, autonomy, use of evidence-based
practice, and creating a culture of excellence for nursing
staff through role modeling, smart allocation of resources
and the development of standards ofexcellence (Gaguski &
Begyn, 2009, p. 385).
Innovative Care Models (
is a program initiated in 2008 that identified 24 successful
collaborative care models for acute care and comprehensive
aftercare developed as part of a research project funded
by the Robert Wood Johnson Foundation. One example
is Collaborative Patient Care Management, a multidisciplinary case management model in which certified RN
PCCs and physicians co-chair practice groups targeting
high-risk, high-cost patient populations.
Accountable Care Organizations (ACOs)
The ACO is a collaboration among primary care and specialist clinicians, a hospital, and other health professionals
accepting joint responsibility for both quality and cost of
care provided to their patients. Under the PPACA, ACOs

Chapter 8 The Kaleidoscope of Collaborative Practice 141
funding and often are not provided by nurses. One blog
describes the navigator as one who works with patients
and families to help them at many points along the
health-care continuum: disease research, insurance problems, finding doctors, understanding treatment and care
options, accompanying them to visits, serving as coach
and quarterback of their health-care team, working with
family members and caregivers, mobilizing resources,
managing medical paperwork and almost anything
else you can think of (Russell, 2013). The role sounds
similar to nursing and more nurses and even physicians
An example of this model is the Patient Navigator
program pioneered by Dr. Harold Freeman at Harlem
Hospital to help eliminate barriers the minority communities
encountered when seeking cancer screening, diagnosis,
treatment, and ongoing care. It can be either hospital or
clinic based. At present, patient advocacy or navigation
is not regulated in its own right, there is no national or
state licensure or credentialing, and the navigator is not
necessarily a nurse. Hospital-based navigators are often
nurses working for the hospital. Private navigator services
may or may not be paid for by insurance or advocate
Box 8.1
TEN New Rules to Redesign and Improve Care
Recommendation 4: Private and public purchasers,
health-care organizations, clinicians, and patients
should work together to redesign health-care processes
in accordance with the following rules:
1. Care based on continuous healing relationships.
Patients should receive care whenever they need it
and in many forms, not just face-to-face visits. This
rule implies that the health-care system should be
responsive at all times (24 hours a day, every day)
and that access to care should be provided over
the Internet, by telephone, and by other means
in addition to face-to-face visits.
2. Customization based on patient needs and values.
The system of care should be designed to meet
the most common types of needs, but have the
capability to respond to individual patient choices
and preferences.
3. The patient as the source of control. Patients should
be given the necessary information and the opportunity to exercise the degree of control they
choose over health-care decisions that affect them.
The health system should be able to accommodate
differences in patient preferences and encourage
shared decision making.
4. Shared knowledge and the free flow of information.
Patients should have unfettered access to their own
medical information and to clinical knowledge.
Clinicians and patients should communicate
effectively and share information.
5. Evidence-based decision making. Patients should
receive care based on the best available scientific
knowledge. Care should not vary illogically from
clinician to clinician or from place to place.
6. Safety as a system property. Patients should be
safe from injury caused by the care system.
Reducing risk and ensuring safety require
greater attention to systems that help prevent
and mitigate errors.
7. The need for transparency. The health-care system
should make information available to patients and
their families that allows them to make informed
decisions when selecting a health plan, hospital, or
clinical practice, or when choosing among alternative treatments. This should include information
describing the systems performance on safety,
evidence-based practice, and patient satisfaction.
8. Anticipation of needs. The health system should
anticipate patient needs rather than simply
reacting to events.
9. Continuous decrease in waste. The health system
should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate
to ensure an appropriate exchange of information
and coordination of care.
(IOM, 2001, Executive Summary, pp. 89)

142 Unit 2 The Practice Environment
teamwork is repeatedly stressed in the IOM report, The
Future of Nursing (2011). Collaboration is considered
intrinsic to nursing, the norm for professional practice,
and a health care imperative (Sullivan, 1998, p. 62).
With health care increasingly provided in complex systems, the interactions of various providers are not only
inevitable but also essential for high-quality holistic care.
However, agreement on basic definitions of medical and
nursing practice is the sine qua non of collaboration
between the sets of providers.
During the tumultuous years of the mid 1990s,
amid national debates regarding comprehensive federal
health-care reform, the leaders of the AMA and the ANA
drafted the following joint definition of collaboration
(ANA, 1998, p. 2):
Collaboration is the process whereby physicians and nurses
plan and practice together as colleagues, working interdependently within the boundaries of their scopes of practice
with shared values and mutual acknowledgment and respect
for each others contribution to care for individuals, their
families and their communities.
Although the ANA board of directors adopted this
definition in 1994, it has yet to be adopted by the AMA.
In considering strategies for successful collaboration,
perhaps revisiting this mutually developed definition with
medical and nursing organizations and practice boards
on a state-by-state basis will provide the groundswell for
a truly meaningful sense of shared practice relationships.
The ongoing work of adopting the APRN Consensus
Model state by state is a positive step in that direction
(OGrady & Ford, 2009).
are becoming private navigators or advocates. However,
many models described in the literature stress that they
prefer a nonmedical or lay person with interpersonal
skills and some experience in service-oriented fields (de
la Riva et al, 2016; Loskutova et al, 2016). Nurses need
to understand the role and work with the navigators as
lay members of the team. In addition, they might consider reshaping their clinical role to have the advocate or
navigator approach.
The call for collaboration continues to accelerate, driven
by consumer and insurer demands for high-quality care
at low cost; the existence of fragmented, disorganized,
impersonal, and inaccessible care; numerous reports
and commissions recommending collaboration; and the
demands of some accrediting agencies for collaboration
(Bodenheimer, 2008; IOM, 2011; Maier & Aiken,
2016; Marshall, 2016; Zwarenstein et al, 1998). The
IOM Committee, in its call for the design of a new
health-care system for the 21st century that better meets
patient needs, recommended that health-care processes
be redesigned in accordance with 10 new rules listed
in Box 8.1 (IOM, 2001). The rules speak to a system of
care delivery focused on continuous healing relationships,
shared knowledge and decision making with patients, and
cooperation among professional providers as reflected by
active collaboration and communication, emphasizing
cooperation in patient care as more important than
professional prerogatives and roles. This emphasis on

Participation of the Advanced
Practice Nurse in Health Plans
and Quality Initiatives
Rita Munley Gallagher
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Support the potential for advanced practice nurses (APNs) to improve both patient experience and health plan (HP) profitability.
Recommend skills needed for APNs to be successful in the managed care
Illustrate the relevance of value-based pricing strategies to APNs.
Demonstrate the benefits of participation in quality reporting programs.
Explain the barriers to autonomous practice by APNs inherent in the health-care
delivery system.
Illustrate the relevance of value-based purchasing (VBP) strategies to APNs.
Support national organizations engaged in quality efforts and participate in quality initiatives.
Present the benefits of integrating measurement into professional nursing practice
at all levels.
Propose the utilization of data to mobilize consumer support for their services.
Defend the need for marketing skills.

are expert at assessing and diagnosing problems. The
treatments they prescribe result in positive outcomes
(American Academy of Nurse Practitioners, 2010). Still,
they are often underutilized by health insurance plans.
HPs have become the overseers and administrators of
health-care services for most Americans. HPs are nearly
ubiquitous, having assumed the management and control of the overwhelming majority of health-care services
provided throughout the entire United States. In 2014,
nearly 90% of the U.S. population was covered under
HPs; the majority (55.4%) were covered in commercial
plans with approximately 35% covered by Medicare or
Medicaid (Smith & Medalia, 2015).
HP leaders are in a position to improve both patient
experience and the HPs bottom line by including more
NPs in a greater number of HPs. APNs are highly cost
effective. Their care results in decreased hospital admissions,
increased adherence to treatment protocols, and improved
patient outcomes (Swan et al, 2015). The number of
APNs is increasing as is the physician shortage, especially
in medically underserved areas. Furthermore, APNs are
already caring for these vulnerable patient populations
in large numbers (Buerhaus, DesRoches, Dittus, &
Donelan, 2015).
Given these findings, understanding the rationale
for not including significant numbers of APNs in HP
provider panels is difficult (Miller, 2014). Almost all HPs
have some sort of managed care program to help control
health-care costs. Managed care includes programs intended to reduce unnecessary health care costs through a
variety of mechanisms, including: economic incentives for
physicians and patients to select less costly forms of care;
programs for reviewing the medical necessity of specific
services; increased beneficiary cost sharing; controls on
inpatient admissions and lengths of stay; the establishment
of cost-sharing incentives for outpatient surgery; selective
contracting with health care providers; and the intensive
management of high-cost health care cases (National
Library of Medicine, 2011). At least in theory, managed
care is designed to foster the effective, appropriate, and
efficient monitoring of a specific populations health.
Managed care calls for providers to assume responsibility
Advanced practice nurses (APNs) continue to be conspicuous
by their absence from health plan (HP) provider panels.
In addition, their efforts have not been fully recognized
in activities within the national quality enterprise. Is this
because of their predominantly employee status? Are they
reluctant to take on the full responsibility of a primary
care provider, fearful of accepting accountability, hesitant
to mobilize consumer support on their own behalf? Or, is
it a more fundamental issuean issue of respect?
Todays evolving health-care environment has transformed the way many health-care services are provided
and compensated. The approach to health-care service
delivery has undergone a significant alteration in both its
contracting and reimbursement mechanisms. Fee-forservice is no longer the primary source of pricing but has
been overtaken by prospective payment, global pricing,
capitation, and value-based purchasing (VBP). Along with
these changes has come a significant increase in financial
risk to the provider. By taking on liability not only for
service delivery costs but also for level of use, providers have
assumed roles historically reserved for insurance carriers.
In addition, demonstration of practitioner accountability
for quality has moved into the forefront of health-care
delivery. More than 260,000 APNs (National Council
of State Boards of Nursing [NCSBN], 2012)and their
numbers are growingare carving out a larger role in
delivering safe, effective, patient-centered, timely, efficient, equitable health care. This chapter focuses on the
involvement of APNs within HPs and within the national
quality enterprise and offers suggestions for increasing
their visibility within both.
APNs possess the education and expert clinical knowledge to practice in multiple settings. The expertise of
APNs serves to complement other practitioners within the
health-care arena. Nurse practitioners (NPs) are proven
to be excellent health-care providers. More than 40 years
of research has established that NPs provide high-quality,
cost-effective and personalized care. The body of evidence
regarding the quality of NP practice supports the notion
that NP care is at least equivalent to that of physician care.
When NP care is compared with that of other providers
such as physicians, NP patients are more satisfied with
their care and say that, in addition to providing excellent
health care, their NP excels in giving health advice. They

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 145
and accountability for the health-care needs of a specifically
defined population while at the same time agreeing to
accept the financial risk inherent in taking on that responsibility. In a managed care system, the insurer determines,
under written standards, the medical necessity of medical
services and directs care to the most appropriate setting so
as to provide high-quality care in the most cost-efficient
manner. To control benefits, HPs require preauthorization
of certain services, careful review of payment of claims,
and maintenance of a provider network. Each of these
administrative functions contributes to lowering the cost
of care by managing benefits closely (Richards, 2010). In
America, we strictly ration health care. Weve done it for
years, says Dr. Arthur Kellermann, professor of emergency
medicine and associate dean for health policy at Emory
University School of Medicine. But in contrast to other
wealthy countries, we dont ration medical care on the
basis of need or anticipated benefit. In this country, we
mainly ration on the ability to pay. And that is especially
evident when you examine the plight of the uninsured in
the United States (Horsley, 2009).
In managed care, the burden of risk is shared. Unlike traditional indemnity plans in which the insurance
company bears the financial risk and burden of enrollees
requiring more complex and costly care, various incentive
plans and capitation place the risk (and burden) on the
managed care providerwhether that be a plan, APN,
physician, mental health provider, or other practitioner
(Managed Care, 2008). In addition to point-of-service
(POS) plans, the most common types of HPs include
health maintenance organizations (HMOs) and preferred
provider organizations (PPOs), a component of which
are exclusive provider organizations. All of them are
grounded in provision of care to a specified cohort of
enrollees at an established per member/per month rate.
See Box 9.1.
The initial goal of managed care was to improve
quality of care and population health by increasing use
of preventive services while controlling costs (Chernof,
2013). This mission has not always been readily apparent
in practice or necessarily shared by all HPs. However, as
systems of managed care have continued to develop, the
goals have expanded to include, among others, a focus on
outcomes analysis, development of practice guidelines, the
creation of provider panels with a host of practitioners,
and the coordination of service provision among providers
(Medicaid and CHIP Payment and Access Commission
[MACPAC], 2011).
State governments have been moving to increase their
regulation of HPs. Many states have passed laws expanding
patient rights; guaranteeing access to care; requiring POS
options, including whistleblower clauses; and establishing provider due process protections. However, several
self-insured HPs have successfully challenged state health
insurance regulations under the Employee Retirement
Income Security Act (ERISA) based on their contention
that they are self-insured employee health benefit plans.
Therefore, these types of plans are exempt from many state
regulations, such as any willing provider and nondiscrimination provisions (Berkery & Vann, 2013).
With a background in patient education and certification in a specialty at the masters level, the APN is well
equipped to provide high-quality care in a cost-effective
environment (American Academy of Nurse Practitioners,
2010). Yet APNs continue to be underrepresented on HP
panels, thereby limiting enrollee access to their services.
This gives rise to suspicions of lack of respect for APNs and
for nursing overall. Managed care has become a way of life
for all health-care practitioners and must include APNs.
Competencies Necessary in the Managed
Care Environment
Clearly managed care is here to stay. However, although
the fit between its stated health promotion and disease
prevention goals is in line with those of the APN, HPs
place emphasis on the bottom line in an often very
competitive market. To prosper in such an arena, several
HMOs usually only pay for care within the network.
The enrollee chooses a primary care provider who
coordinates most of the enrollees care.
PPOs generally pay more if the enrollee receives
care within the network, but a PPO still pays a
portion if the enrollee goes outside the network.
POS plans let the enrollee choose between an HMO
and a PPO each time care is needed.
Box 9.1
Types of Managed Care Plans

detail the processes established to ensure quality improvement
and outcomes of activities. Administrative expertise is needed
and quality and financial reporting mechanisms must be in
place. Operating standards focused on efficacy and outcome
measurement criteria along with practitioner performance
evaluations are also closely scrutinized by the HP (Anthem
Blue Cross, 2015). At a minimum, it is assumed that all
parties preparing to enter into a contract do so voluntarily
and knowingly having read and fully understanding the
document. Failing to read the contract critically, as well
as failure to have it reviewed by an attorney, can result in
significant problems for the APN at a later date.
Contracting With Health Plans
Several challenges are inherent in providing health-care
services, which makes the decision to enter into a contractual agreement with a HP particularly attractive and also
potentially difficult. Such challenges may also result in a
significant number of APNs continuing in the traditional
role of employee, albeit with an HP as employer instead
of the traditional hospital or nursing home. The majority
(74.7%) of respondents to the American Association of
Nurse Practitioners (AANP, 2015) compensation survey
were salaried, whereas 22.5% were paid an hourly rate
and 2.8% were self-employed.
When an APN does consider entering into a contract
with a HP, numerous questions arise (Jones & Mills, 2006):
Does the HP need additional APNs in your geographic
area? Is the HP planning to bid on an employer group
whose employees heavily utilize your specialty? Do you
offer any unique services that will benefit the HP and its
members? These and other relevant issues must be clarified by the APN before contractual integration into any
HP system. Clearly prospective planning is critical in the
decision-making process preparatory to contracting with
an HP. See Box 9.2.
APNs must know whether the HP with which they
are negotiating does the following:
Confronts the realities of providing adequate care to
Supports strong research and development programs
Promotes health education and disease prevention
Strongly integrates the perspectives of relevant enrollee
Promotes collaborative care
skills are needed. These include marketing, advertising, and
finance, which are generally considered as being beyond
the components of (and, therefore, not included in) the
basic nursing curriculum.
To form an optimal system of managed care, a new
paradigm of professional practice may be needed. In this
new system, the practitioner needs to be capable of
integrating the traditional curing focus with an ability to
manage the health of individual enrollees and the covered
cohort overall. In addition to appropriate credentials,
APNs must possess the following skills to be successful
in managed care:
Clinical accountability
Communication skills
Leadership skills
Team-building abilities
Negotiation and conflict resolution skills
Ability to engage in quality management activities
Financial acumen
APNs who see themselves as possessing these competencies
can improve their chances of successfully negotiating a
contract with a HP by doing the following:
Highlighting communication; enhancing documentation; becoming familiar with the ins and outs of
the contract
Being ready to follow through with commitments
Educating HPs on the valueboth quality value and
efficiency valueof their services
Improving fiscal and management system capacities
Being creative, flexible, and willing to work with the
HP to meet mutual goals
To operate successfully in the HP environment, it is crucial that APNs work collaboratively with case managers,
identify gaps in service that they are capable of filling, and
hone the skills necessary (see the previous list) to succeed
in contracting with the HP as well as in securing needed
benefits on behalf of their enrollees (Centers for Medicare
and Medicaid Services [CMS] Medicare-Medicaid Coordination Office, 2013).
HPs are interested in a providers ability to furnish financial and cost data cross-referenced by client characteristics.
These characteristics include clinical complexity, resource
utilization, therapy and pharmaceutical use, length of stay,
and outcome criteria. In addition, the APN must be able to

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 147
Budget Reconciliation Act (OBRA) of 1989 allowed for
Medicaid coverage of services by family NPs and pediatric NPs and extended Medicare Part B coverage to NPs
in skilled nursing facilities only (with no provision for
coverage of services provided by clinical nurse specialists
[CNSs]) and with the payment going to the facility, not
directly to the NP. Medicare Part B coverage was extended
to services provided by both NPs and CNSs in nonmetropolitan statistical areas (i.e., rural areas) by OBRA 90,
establishing NPs and CNSs as Medicare providers. The
1990s saw several attempts by the American Nurses Association (ANA) and others to expand coverage for APN
services, culminating with the signing of the Balanced
Budget Act (BBA) of 1997 by President William Jefferson
Clinton. The BBA extended reimbursement opportunities
for APNs by removing geographical and practice site
restrictions (ANA, 2016). However, significant barriers
to full and autonomous practice for APNs remain firmly
entrenched in the health-care delivery system. Federal
(and many state) laws do not provide adequate support
for the removal of barriers to practice for APNs that are
created by policy makers, health-care institutions, insurance payers, or HPs. These barriers include denial of
claims from third-party payers; failure to include APNs
on preferred provider panels; institutional and provider
policies that inhibit the objective and accurate assessment of the quality of care and benefits provided by use
of APNs; and institutional and provider limitations on
APN scope of practice (SOP), including contracting with
HPs. Although the BBA did allow for direct Medicare
reimbursement for services provided by NPs and CNSs
regardless of geographical location or practice setting, it
was at only 85% (80% for CNSs) of the amount that
Medicare reimbursed physicians. This inequity resulted
in continued billing for APN services as incident to the
physician (i.e., allowing a service provided by an APN to
be billed at 100% of the fee schedule when the physician is
on site and available for consultation, if necessary) adding
to the invisibility of APNs.
Also of relevance is Medicares payment system, which
has historically rewarded quantity rather than quality of
care, providing neither incentive nor support to improve
health-care quality. Conversely, the current system of
VBP links payment more directly to the quality of care
provided. This strategy transformed the payment system
by rewarding providers for delivering high-quality, efficient
Supports patient engagement
Collects and disseminates accurate data
Advocates for financing reforms that better fund
primary care
Does a thorough job of attending to psychosocial factors
Promotes palliative care, when appropriate
Educates the public on the benefits of a healthy lifestyle
Incentivizes APNs commensurate with the risks they
When Medicare and Medicaid were first enacted in 1965
by amendment of the Social Security Act, few nurses were
practicing independently; thus, no provisions were made
for direct payment to them. Enactment of the Omnibus
Following are six tips for successful contracting with
a health plan (HP):
1. Do your homework! Know as much as possible
about the plan before you start to negotiate a
contract. If you can, talk with other practitioners
already on the provider panel.
2. Be a tough but fair negotiator up front and
then a team player once you have signed on. If
you want to make changes in the contract, do
it before signing, not after.
3. Evaluate the attitude of the plan and cultivate
a relationship with its officials. Do not expect
plans to improve after you have signed on.
4. Clarify ambiguous language. Refine issues
prospectively rather than trying to negotiate
substantive changes after signing. Start with
the less important issues when negotiating. It
is important to know what you want and to
know your limits.
5. Pay particular attention to any specific processes
required by the HP in relationship to the transfer
of a patient (Buppert, 2008).
6. Finally, seek competent legal advice to avoid
contracting pitfalls. The health plan does.
Box 9.2
Tips for Contracting With Health Plans

Schedule (MPFS)-covered professional services provided
in 2013. APNs who report satisfactorily for the 2016
program year will avoid the 2018 PQRS negative payment
adjustment (CMS, 2016).
The Patient Protection and Affordable Care Act
(PL 111-148) (ACA) links payment to the quality of patient
outcomes and calls for transforming the health-care delivery
system, in part through VBP, to foster improvement in the
quality and efficiency of health care. Demonstrations to test
payment incentive and service delivery models that utilize
physician- and nurse practitioner-directed home-based
primary care teams designed to reduce expenditures and
improve health outcomes are but one example of programs
being instituted. P.L. 111-148 also allows nurse practitioners
and clinical nurse specialists to order post-hospital extended
care services. Access to care provided by certified nurse
midwives is improved through increased reimbursement
for their services. Nurse practitioners will have the ability
to write orders so that patients can continue to receive
hospice services (Gallagher, 2010).
In addition to the potential impact on reimbursement,
participation in quality activities is important because it can
improve health care. Health-care professionals, including
APNs, can participate in several quality activities, including
those sponsored by CMS. The CMS programs are voluntary
activities that indicate health-care professionals and group
practices have a commitment to quality care. In addition
to Hospital Compare, the CMS quality programs include:
Physician Quality Reporting System (PQRS)
PQRS Maintenance of Certification Program Incentive
Consumer Assessment of Healthcare Providers &
Systems (CAHPS) for PQRS
Electronic Health Record (EHR) Incentive Program
Million Hearts
Showing a commitment to quality is the first step in
achieving quality care.
Advanced Practice Nurse Participation
in Health Plans
Great strides have been made in recent years to establish
APNs as independent practitioners providing health-care
services. Health-care consumers are accepting APNs practices more widely than previously. Research has continued
to demonstrate over time that APNs have established
clinical care. The Centers for Medicare and Medicaid Services (CMS) launched its VBP initiative through several
public reporting programs, demonstration projects, pilot
programs, and voluntary efforts in hospitals, physicians
offices, nursing homes, home health services, and dialysis
facilities. There is administrative as well as evidentiary
support for VBP. Higher spending does not equate with
higher quality, and VBP is working to improve quality
and avoid unnecessary costs.
In 2006, Congress passed Public Law 109-171, the
Deficit Reduction Act of 2005 (DRA), which under Section
5001(b) authorized CMS to develop a plan for VBP for
Medicare hospital services commencing with fiscal year 2009
when CMS added additional conditions to the hospitalacquired conditions provision (DRA Section 5001[c]).
Scoring in the hospital inpatient VBP program is based
on whether a provider meets or exceeds the performance
standards established with respect to selected measures.
In adopting this program, CMS rewards hospitals based
on actual quality performance, rather than simply reporting data for those measures (Department of Health and
Human Services, 2011, May 6). Therefore, CMS (and
several other third-party payers) no longer make higher
payments for selected conditions such as complications
of surgery or hospital-acquired infections that were not
present at the time of hospital admission (CMS, 2012).
Although early VBP strategies were focused solely on
hospitals, there are also aspects directed to home health care
and to practitioners, including those related to resource
use that should be particularly relevant to APNs. On
December 20, 2006, Public Law (PL) 109-432, the Tax
Relief and Health Care Act of 2006 (TRHCA), was signed.
Division B, Title I, Section 101 of the law authorized the
establishment of a physician quality reporting program by
CMS. The Physician Quality Reporting System (PQRS)
(initially the Physician Quality Reporting Initiative [PQRI])
is a quality reporting program that encourages individual
eligible professionals (EPs), including APNs and group
practices, to report information on the quality of care to
Medicare. PQRS gives them the opportunity to assess the
quality of care they provide to their patients. By reporting
on PQRS quality measures, APNs can also quantify how
often they are meeting a particular quality metric. In
2015, the program began applying a negative payment
adjustment to those who did not satisfactorily report data
on quality measures for Medicare Part B Physician Fee

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 149
application and interpretation of state insurance law can
adversely affect reimbursement and HP plan inclusion
of APNs. To lend conformity and simplify regulatory
compliance, HPs have generally resorted to application
of the most rigorous (and hence most restrictive) rules
promulgated among the states in which they provide
services. The Nondiscrimination of Health Care section
of the ACA (Section 2706) states that an insurer shall
not discriminate with respect to participation under the
plan or coverage against any health care provider who is
acting within the scope of that providers license or certification under applicable state law. The intent of this
provision is to provide patients with access and choice of
health-care provider, including such providers as NPs,
without discrimination. By complying, HPs are acting
in their own best interests as well as the best interests of
patients (Miller, 2014). APNs must continue to direct
their efforts toward ensuring that additional states enact
such legislation and that HPs allow them the recognition
they so richly deserve. Whether the APN intends to work
as an employee of an HP or to seek inclusion on an HPs
provider panel by contracting with one, there is a need
to develop a base of consumer support.
The issue is not one of APNs competence or of the
quality of the care they provide. Decades of reports have
documented the high quality of NP practice (AANP,
2013). Nurses have topped Gallups honesty and ethics
ranking every year but one since they were added to the
list in 1999. (The exception is 2001, when firefighters
were included on the list on a one-time basis, shortly after
the September 11 terrorist attacks. Firefighters earned a
record-high 90% honesty and ethics rating in that survey.)
With an 85% honesty and ethics ratingtying their high
pointnurses have no serious competition atop the Gallup
ranking (Gallup Organization, 2015). Yet, it has been said
that nursesnot just APNs, but all nursesare invisible
in health care (Davis, 2012). However, that perspective
is changing. A 2002 poll commissioned by Johnson and
Johnson found only 25% of those polled had ever heard
of a NP (Johnson & Johnson Poll, 2002, p. 14). Conversely,
most respondents (90%) to a later survey knew about NPs
and the majority had seen a NP for their care. Eighty-two
percent of NP users were satisfied or very satisfied with the
care they had received compared with a 70% satisfaction
rate for other providers (Brown, 2007). Nevertheless, the
skills of many APNs remain underutilized.
and built on a record of delivering high-quality health
care. Despite this fact, there are continuing indications
that APNs face significant barriers in the health-care
marketplace, including the absence of full access to HP
provider panels. Despite the 2012 creation of the Council
for Affordable Quality Health Care Universal Provider
Datasource, designed to simplify the provider credentialing
process, APNs continue to experience significant barriers
in the credentialing process with HPs, to inclusion on
HP provider panels, and to being listed in HP provider
directories. The result of these barriers is that consumers
choice of providers is limited. Furthermore, the APNs
role is relegated to employee in many cases, as opposed
to that of independent contractor, as is the case of most
other classes of practitioners. In addition to barriers to
inclusion on HP panels, insurers and employers have
also added arbitrary restrictions to APNs practices such
as adding physician supervision or needless patient record
cosignatory requirements. These requirements are not necessarily in adherence with state practice laws and increase
the cost of APNs services, thereby creating disincentives
to employers and consumers to use APNs.
A secondary issue is that there is little data collection
regarding the role of APNs in HPs. Most HMOs do
not have formal methods for estimating and reporting
nonphysician provider care, thus making it difficult to
track APN use, efficiency, quality, and credentialing. With
disparities in prescription labeling, it is equally hard to
track APN prescribing patterns. These impediments make
APNs the invisible providers, caring for many patients
and generating revenue without recognition of their efforts
(OGrady, 2008).
The practice environment in the states in which they
are chartered influences the policies of HPs. The legal
definition of APN SOP, the type of physician collaboration
required (or not required), prescription-writing authority,
and state insurance laws may all affect the reimbursement
and use of APNs. As health-care delivery systems evolve
into increasing numbers of multistate HPs, the procedures
and policies affecting APNs are not always clear. In some
cases, the multistate corporations may elect to establish their
own sets of rules instead of following state law. Multistate
policies tend to diminish use of the separate states APN
scopes of practice, sometimes substituting stricter physician collaboration policies or limiting nurses prescriptive
writing authority to HP formularies. Yet, inconsistent

warrant the inclusion of CRNAs in future rulemaking
(American Hospital Association [AHA], 2016).
Yet another strategy that has been put forth by organized
medicine is advocating for the relaxation of antitrust laws
as they apply to health-care professionals. Legislation has
also been introduced on both the federal and state levels
to provide collective bargaining rights for health-care
professionals. Only those employees deemed nonsupervisory under the National Labor Relations Act are accorded
the rights to collectively bargain; however, these legislative
proposals would provide physicians the right to enter into
joint negotiations with insurance companies to work out
payment arrangements, clinical practice conditions, and
more. Such activity is currently forbidden under state and
federal antitrust laws and is considered anticompetitive
collaboration among competitors. In some instances the
courts have held that such collaboration on prices and
market access are illegal boycotts. Changes in law being
advocated by physician organizations would not only allow
negotiation, but also would weaken the ability of the APN
to prove antitrust violations by physician competitors,
thereby ignoring their ability to take part equally in the
competitive managed care arena regardless of the quality
of the care they provide.
Examples of other barriers include limitations on
prescriptive authority, such as the ability to prescribe only
a 30-day supply of Schedule II drugs, and opposition to
removal of the APN-to-physician ratio. This high degree
of variation across the states for APN regulation has spotlighted the need to ensure that regulation serves the public,
promotes public safety, and does not present unnecessary
barriers to patients access to care (OGrady, 2008, p. 8).
The public concern for error and patient safety together
with the continuing quest for quality has created renewed responsibility and accountability for the outcomes
of patient care. The National Quality Forum (NQF), a
private, nonprofit, voluntary, consensus standard setting
organization composed of more than 400 organizations
(including several nursing organizations, the first of which
was the ANA) and individuals from federal and state
governments and private sector entities is prominent in
the national quality arena. NQF is governed by a board of
As ANA and the state nurses associations continue to
advocate for the right of APNs to fully practice within
their scope without arbitrary barriers, physicians have
stepped up efforts to confine the practice of APNs. For
decades, organized medicine has fostered comprehensive
grassroots and media campaigns to promote supervised,
collaborative practice between physicians and APNs and
has increased its public opposition to the expanded scope
and independent practice of APNs (Mukherjee, 2013).
One of the latest assaults of organized medicine was
directed at APNs practicing in the Department of Veterans
Affairs (VA), which proposed a rule to grant full practice
authority to APRNs when they are acting within the scope
of their VA employment. Full practice authority would
help optimize access to VA health care by permitting
APRNs to assess, diagnose, prescribe medications, and
interpret diagnostic tests. This action proposed to expand
the pool of qualified health-care professionals authorized to
provide primary health care and other related health-care
services to the full extent of their education, training, and
certification to veterans without the clinical supervision
of a physician. All VA APRNs are required to obtain
and maintain current national certification. According
to VA Under Secretary for Health Dr. David J. Shulkin,
Implementation of the final rule would be made through
VHA policy, which would clarify whether and which of
the four APRN roles (certified registered nurse anesthetist
(CRNA), certified nurse-midwife (CNM), CNS, certified
nurse practitioner (CNP)) would be granted full practice
authority. At this time, VA is not seeking any change to
VHA policy on the role of CRNAs, but would consider a
policy change in the future to utilize full practice authority
when and if such conditions require such a change (VA,
2016). Organized medicine decried the proposal because,
according to the American Medical Association (AMA),
it runs counter to physician-led, team-based care, which
it called the best approach to improving quality (Lowes,
2016). In late 2016, the Department of Veterans Affairs
issued a final rule allowing certain APRNsCNPs,
CNSs and CNMsto practice to the full extent of their
education and training within the agency. Among other
provisions, the rule defined the scope of full practice
authority for the three APRN roles, which are consistent
with the nursing professions standards of practice. The
rule excludes CRNAs but requested comment on whether
access issues or other unconsidered circumstances might

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 151
measures for evaluating the performance of nursing in
acute-care hospitals (NQF, 2007). It also addressed the
implementation of those measures within health-care organizations to improve nursing care and patient outcomes
and designated a subset of measures that are appropriate
for public reporting (such as on the Web site Hospital
Compare, which was developed by the Hospital Quality
Alliance [HQA] in which the ANA was a principal).
HQA developed and launched Hospital Compare to
provide information to the public on hospital quality. HQA
worked to increase hospitals voluntary participation in
public reporting and expand the set of quality measures
being reported. The information on Hospital Compare
helps patients determine how often individual hospitals
provide the specific care that most patients should receive
for certain conditions, such as giving heart attack patients
an aspirin on arrival at a hospital. Although only a limited
number of nursing measures are included in Hospital
Compare, the sheer number of nurses and their primacy
in caregiving are compelling reasons for measuring their
contribution to patients experiences and the outcomes
that are attained (NQF, 2007). See Box 9.3.
The Joint Commission engaged in a comprehensive
test of the NQF nursing-focused performance measures
to determine whether they could be used nationally to
identify opportunities to improve the quality of patient
care provided by nurses. The project was funded by a grant
from the Robert Wood Johnson Foundation. Testing of
the integrated set of measures led to refined technical
specifications. The resultant measures then underwent
NQF investigation and most were re-endorsed. They
are now available for use by hospitals nationwide and
included in quality initiatives used by the CMS and/or
The Joint Commission (Hill, 2007). The information
available to assist consumer decision making (such as is
provided on Hospital Compare) would be greatly enhanced
by the inclusion of the full portfolio of NQF-endorsed
nursing-sensitive measures. See Box 9.4.
Advanced Practice Nurse Participation
in Quality Initiatives
In addition to the NQF-endorsed nursing-sensitive measures,
other clinician-level quality measures are of relevance to
APNs, including those developed by the Physician Consortium for Performance Improvement (PCPI) convened
directors representing health-care consumers, purchasers,
providers, HPs, and experts in health services research.
The NQF board also includes representatives from four
federal agencies: the Agency for Healthcare Research and
Quality (AHRQ), the Centers for Disease Control
and Prevention (CDC), CMS, and the Health Resources
and Services Administration (HRSA) (NQF, 2016b).
The mission of NQF is to lead national collaboration
to improve health and health-care quality through measurement by:
Convening key public- and private-sector leaders to
establish national priorities and goals to achieve health
care that is safe, effective, patient-centered, timely,
efficient, and equitable
Working to ensure that NQF-endorsed standards
will be the primary standards used to measure and
report on the quality and efficiency of health care in
the United States
Serving as a major driving force for and facilitator of
continuous quality improvement of American health-care
quality (NQF, 2016c).
Nursing is active in all aspects of NQF efforts on steering
committees and their technical advisory panels: the National
Priorities Partnership, the Consensus Standards Advisory
Committee (CSAC), and the NQF board of directors.
The central activity of NQF is the endorsement of performance measures as voluntary consensus standards and
the identification of gaps in health-care quality research.
Voluntary consensus standards, although relatively new
in the health-care arena, are not new to other industries.
Moreover, since passage of the National Technology Transfer and Advancement Act of 1995 (Public Law 104-113)
voluntary consensus standards have legal standing. The
voluntary consensus process, even in the face of strict requirements as to periods and transparency, is timelier than
is the federal rule-making process. One key component of
the act is the obligation of the federal government to use
voluntary existing consensus standards, thus encouraging
the federal government to take part in the NQF process.
Federal agency involvement in NQF serves to encourage
both public and private purchasers, accrediting bodies,
practitioners and providers, and the public to also take part.
NQF recognizes the value of nursing to health-care
quality. The NQF nursing care performance measures
project established consensus on a set of evidence-based

Box 9.3
The Value of Measuring Nursing Care
To increase the value of information provided to
consumers regarding the quality of nursing care by
nursing-sensitive measures, interested parties should
focus on the following points:
1. Nurses represent the largest single group of healthcare professionals.
Registered nurses held about 2.8 million jobs in
2014 (Bureau of Labor Statistics [BLS], 2016).
In initially endorsing voluntary consensus standards
for nursing-sensitive care, the National Quality
Forum (NQF) noted nurses, as the principal
frontline caregivers in the U.S. health-care system, have tremendous influence over a patients
health-care experience (NQF, 2004).
2. Decades of evidence demonstrate nursings impact
on the provision of care that is safe, effective, patient
centered, timely, efficient, and equitable:
RNs play key roles in hospitals systems for early
detection of threats to patient safety and for prompt
remedial intervention (Dubois et al, 2013).
A high level of evidence indicated better serum
lipid levels in patients cared for by NPs in primary
care settings (Stanik-Hutt et al, 2013).
Patient outcomes on satisfaction with care, health
status, functional status, number of emergency
department visits and hospitalizations, blood
glucose, blood pressure, and mortality are similar
for NPs and MDs (Stanik-Hutt et al, 2013).
Increasing RN staffing could reduce costs and
improve patient care by reducing unnecessary
deaths and reducing days in the hospital (Stone
et al, 2007).
A 10% increase in the number of patients assigned
to a nurse leads to a 28% increase in adverse
events such as infections, medication errors, and
other injuries (Weisman, 2007).
Understaffing of RNs in hospital intensive care units
increases the risk for serious infections for patients,
specifically pneumonia (Hugonnet, Ukay, &
Pittet, 2007).
According to The Joint Commission (2005),
quantifying the effect that nurses and nursing
interventions have on the quality of care processes, and on patient outcomes, has become
increasingly important to support evidence-based
staffing plans, understand the impact of nursing
shortages and optimize care outcomes.
3. Measures of quality have been fully developed, are in
use, and have been previously vetted. The endorsement
of the nursing-sensitive measures by NQF was an
initial (albeit significant) step toward standardized
measurement of nursing care, detailing its relationship to the quality (and efficiency) of health care.
Nursing-sensitive indicators are widely used as a
barometer of quality care by CMS, the Patient
Care Link, and the Magnet Recognition Program
(Erickson, 2011). Collectively, the measures
provide consumers a way to assess the quality
of nurses contribution to inpatient hospital care,
and they enable providers to identify critical
outcomes and processes of care for continuous
improvement that are directly influenced by
nursing personnel (NQF, 2004).
4. There has been a public call for information about
nursing care quality.
Enhancing the initial nursing-sensitive measure
set through the inclusion of additional measures
will increase the overall value of the set.
Consumers will benefit from information regarding the impact of nursing care as they make
decisions regarding care.
5. Evidence exists that public reporting stimulates
quality improvement and choice.
Making performance data public results in
improvements in the clinical area reported on
(Hibbard, Stockard, & Tusler, 2005).
6. Measuring and publicly reporting health-care quality
information results in higher-quality care for patients
(MN Community Measurement, 2015). There is
agreement among diverse health-care stakeholders

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 153
that the NQF-endorsed nursing-sensitive measures
should be incorporated into national and state hospital
performance measurement and reporting activities.
Interviews were conducted with nearly three dozen
national health-care, hospital, and nursing leaders,
principals of nursing performance measurement
efforts, and hospital representatives to determine
their interest in and use of the NQFs nursingsensitive measures. Recommendations derived
from the data gathered from these interviews
and published by NQF (2007) point to several
complementary and incremental actions that
can be collectively undertaken by health-care
stakeholders to advance hospital performance
measurement and accelerate our collective understanding of nursings key role in quality. Among
these recommendations is a call to health-care
leaders to fully integrate the nursing-sensitive
measures into national and state hospital performance measurement and reporting initiatives,
including, but not limited to, Hospital Compare
(NQF, 2007; USDHHS, 2012).
Box 9.4
National Quality ForumEndorsed National Voluntary Consensus Standards for Nursing-Sensitive Care1
Patient-centered outcome measures:
1. Death among surgical inpatients with serious, treatable complications (PSI 4): In-hospital deaths per
1,000 surgical discharges, among patients ages 18
through 89 years or obstetric patients, with serious
treatable complications (deep vein thrombosis/
pulmonary embolism, pneumonia, sepsis, shock/
cardiac arrest or gastrointestinal hemorrhage/
acute ulcer). Includes metrics for the number of
discharges for each type of complication. Excludes
cases transferred to an acute care facility.
2. Pressure ulcer prevalence (hospital acquired): The total
number of patients who have hospital-acquired (nosocomial) category/stage II or greater pressure ulcers
on the day of the prevalence measurement episode.
3. Patient fall rate: All documented falls, with or
without injury, experienced by patients on eligible
unit types in a calendar quarter.
4. Falls with injury: All documented patient falls with
an injury level of minor or greater on eligible unit
types in a calendar quarter. (Reported as injury
falls per 1,000 patient days.)
5. Restraint prevalence (vests and limb): Total number
of patients who have vest and/or limb restraint
(upper or lower body or both) on the day of the
prevalence measurement episode.
6. National Healthcare Safety Network (NHSN)
catheter-associated urinary tract infection (CAUTI)
outcome measure: Standardized infection ratio
(SIR) of health-care-associated, CAUTI will be
calculated among patients in bedded inpatient
care locations, except level II or level III neonatal
intensive care units (NICU). This includes acute
care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals,
and behavior health hospitals.
7. Percent of residents with a urinary tract infection
(long-stay): This measure reports percentage of
long-stay residents who have a UTI in the 30 days
before the target assessment. This measure is based
on data from the minimum data set (MDS 3.0)
OBRA, PPS, or discharge assessments during the
selected quarter. Long-stay nursing facility residents
are identified as those who have had 101 or more
cumulative days of nursing facility care.
8. Risk-adjusted urinary tract infection outcome measure after surgery: Risk-adjusted, case mix adjusted
UTI outcome measure of adults 18+ years after
surgical procedure.
9. Urinary tract infection admission rate (PQI 12):
Admissions with a principal diagnosis of UTI
per 100,000 population, ages 18 years and older.
Excludes kidney or urinary tract disorder admissions,

more than a decade ago by AMA. Its goal is to improve
patient health and safety by:
Identifying and developing evidence-based clinical
performance measures and measurement resources
that enhance the quality of patient care and foster
Promoting the implementation of effective and relevant
clinical performance improvement activities
Advancing the science of clinical performance measurement and improvement
Consortium activities are carried out through cross-specialty
work groups established to develop performance measures
from evidence-based clinical guidelines for select conditions.
Membership is open to any organization or individual
who is committed to health-care quality improvement or
patient safety and who participates in the development,
review, dissemination, or implementation of performance
measures and measurement resources. The PCPI balances
its work efforts among new measure development, maintenance and enhancement, specifications, measure testing,
and implementation. New measure topics are reviewed
and selected against criteria including addressing gaps
and unexplained variations in care, quality improvement,
patient safety, appropriateness of care, and key priorities
of the current health-care environment. The multiple
Endorsed as of July 8, 2016 (NQF, 2016a).
other indications of immunocompromised state
admissions, obstetric admissions, and transfers
from other institutions.
10. National Healthcare Safety Network (NHSN) central
line-associated bloodstream infection (CLABSI) outcome
measure: SIR of health-care-associated, CLABSI will
be calculated among patients in bedded inpatient
care locations. This includes acute care general hospitals, long-term acute care hospitals, rehabilitation
hospitals, oncology hospitals, and behavioral health
hospitals. Nursing-centered intervention measures
system-centered measures:
11. Skill mix (registered nurse [RN], licensed vocational/
practical nurse [LVN/LPN], unlicensed assistive
personnel [UAP], and contract):
NSC-12.1Percentage of total productive
nursing hours worked by RN (employee and
contract) with direct patient care responsibilities
by hospital unit.
NSC-12.2Percentage of total productive nursing hours worked by LPN/LVN (employee and
contract) with direct patient care responsibilities
by hospital unit.
NSC-12.3Percentage of total productive
nursing hours worked by UAP (employee and
contract) with direct patient care responsibilities
by hospital unit.
NSC-12.4Percentage of total productive nursing
hours worked by contract or agency staff (RN,
LPN/LVN, and UAP) with direct patient care
responsibilities by hospital unit.
12. Nursing hours per patient day:
NSC-13.1 (RN hours per patient day)The
number of productive hours worked by RNs with
direct patient care responsibilities per patient day
for each in-patient unit in a calendar month.
NSC-13.2 (Total nursing care hours per patient day)The number of productive hours
worked by nursing staff (RN, LPN/LVN, and
UAP) with direct patient care responsibilities
per patient day for each in-patient unit in a
calendar month.
13. Practice Environment ScaleNursing Work
Index (PES-NWI) (composite and five subscales):
PES-NWI is a survey measure of the nursing
practice environment completed by staff RNs,
which includes mean scores on index subscales
and a composite mean of all subscale scores.
Box 9.4
National Quality ForumEndorsed National Voluntary Consensus
Standards for Nursing-Sensitive Care1 (Continued)

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 155
step process for measure development begins with a
review of evidence and selection of a work group and
continues through public comment and member voting.
Specifications and eMeasures (standardized performance
measures specified in the accepted standard health quality measure format) are developed for implementation
into an EHR. Practitioners of all relevant disciplines
of medicineas well as other health-care professionals
for whom the care topic is within their SOP, including
APNsare involved in each measure work group (Kmetik, 2007). The PCPI eSpecification, which provides the
requirements for writing and calculating the measure in an
electronic environment, includes human readable format,
and the PCPI eMeasures translate the eSpecifications into
a computer readable format. The PCPI tests many of its
performance measures for feasibility, reliability, validity,
and unintended consequences via PCPI-convened testing networks (AMA, 2016). PCPI is the sole developer
or a collaborating party for a portfolio that includes
measurement sets in 47 clinical areas and preventive care
and more than 350 individual measures (AMA, 2016a,
2016b). See Box 9.5.
Nurses are the primary caregivers in all health-care settings.
As such, they are critical to the provision of high-quality
Box 9.5
Physician Consortium for Performance Improvement: Quality Measures Relevant to APNs
Physician Consortium for Performance Improvement
(PCPI) measurement descriptions and specifications
are available for the following 48 clinical topics and
1. Acute otitis externa (AOE)/otitis media with
effusion (OME)
2. Adult sinusitis
3. Anesthesiology and critical care
4. Asthma
5. Atopic dermatitis
6. Atrial fibrillation and atrial flutter
7. Care transitions
8. Chronic obstructive pulmonary disease
9. Chronic stable coronary artery disease (Updated
as of April 2016)
10. Chronic wound care
11. Community-acquired bacterial pneumonia
12. Dementia (Updated as of December 2015)
13. Diabetesadult
14. Emergency medicine
15. Endoscopy and polyp surveillance
16. Eye care I and II (Updated as of August 2015)
17. Gastroesophageal reflux disease
18. Geriatrics
19. Heart failure (Updated as of April 2016)
20. Hematology
21. Hepatitis C (Updated as of June 2016)
23. Hypertension
24. Kidney diseaseadult
25. Kidney diseasepediatric
26. Major depressive disorderadult (Updated as of
September 2015)
27. Major depressive disorderchild and adolescent
(Updated as of December 2015)
28. Maternity care
29. Melanoma
30. Nuclear medicine
31. Obstructive sleep apnea
32. Oncology (Updated as of September 2015)
33. Optimizing patient exposure to ionizing radiation
34. Osteoarthritis
35. Osteoporosis
36. Outpatient parenteral antimicrobial therapy
37. Palliative care
38. Pathology
39. Pediatric acute gastroenteritis
40. Percutaneous coronary intervention
41. Perioperative care
42. Prenatal testing
43. Preventive care and screening (Updated as of
April 2016)
44. Prostate cancer (Updated as of September 2015)
45. Radiology
46. Rheumatoid arthritis
47. Stroke and stroke rehabilitation
48. Substance use disorders

Marketing begins with a survey of the desires, needs,
and expectations of the customer, which in managed
care is the enrollee. Armed with that information, APNs
should then structure a plan to meet those needs. Because
most APNs practice in a specialty area, the marketing
plan should focus on the provision of related services,
known as a market segment. An APN can choose to focus
on a population with a single condition (e.g., individuals
with insulin-dependent diabetes), a specific enrollee need
(e.g., rehabilitation following amputation), or a particular
population (e.g., older adults). A primary decision centers
on whether to engage in provision of services to a single
population, a variety of populations, or to all plan enrollees.
Marketing principles are sometimes referred to as the
four Ps: product, price, promotion, and place (NetMBA,
2008). The first P, product, encompasses the specialty
practice services APNs provide amplified by health promotion and disease prevention skills. The APNs product
is self-evident. Thorough understanding of the second
P, price, is essential to the success of the APN, be it within
an HP or in independent practice. Although the marketplace
itself has a significant impact on demand for an APNs
services as well as on how much it is willing to pay, the
APN is the final arbiter regarding price. It is critical that the
APN has full knowledge of the costs of all the components
of the services delivered, not just personal compensation.
The most difficult P for many nurses, not just APNs,
to engage in is promotion. Nurses do not usually excel at
tooting their own horns. Self-promotion, or marketing, is
unfamiliar to most nurses. Nurses generally operate from a
mindset that views all health-care providers as doing their
utmost to provide high-quality care. To increase recognition as well as consumer or enrollee support, APNs must
be willing to call attention to the positive aspects of the
safe, effective, patient-centered, timely, efficient, equitable
care they provide. Finally, APNs must make an informed
decision as to the last P, place; that is, whether or not to
engage in providing care as an employee, as an independent
practitioner, or as a contractual partner in an HP.
Todays health-care delivery system, with increased merger
activity between insurance companies and health-care systems
and the biased policies of providers and HPs, has created
care. Gaining a more in-depth understanding of the role
that nurses play in quality improvement and the challenges
nurses face can provide important insights about how
hospitals can optimize resources to improve patient care
quality (Draper, Felland, Liebhaber, & Melichar, 2008).
All nurses must have thorough evidence-based knowledge
of the impact of the care they provide on the outcomes
that patients experience. Measurement must be integrated
into professional nursing practice at all levels, including
the practice of APNs, and not simply considered to be a
separate activity.
APNs are health-care professionals who do the following
(The University of Tennessee Health Science Center College
of Nursing, 2016):
Provide high-quality health-care services
Diagnose and treat a wide range of health problems
Stress both care and cure, using a unique approach
Focus on health promotion, disease prevention, health
education, and counseling
Assist patients to make wise health and lifestyle choices
Simply put, APNs engage in many of the care practices
that patients are seeking. APNs focus primarily on health
promotion and disease preventionfactors frequently
overlooked by traditional primary care providers. They have
significant experience in both the acute and ambulatory
care arenas. These abilities coupled with APNs possession
of case management skills make them ideal for involvement
in HPs not merely as employees but as fully credentialed
members of the HPs provider panel. Why, then, are HPs
not clamoring to engage their services? How can APNs
increase HPs demand for their services? In short, how
can APNs market themselves (and their advanced practice
roles) to both the HP and its enrollees?
Although continuing emphasis is placed on quality,
managed cares focus on reduction of costs has often resulted
in a type of managed competition in which enrollees
benefits are restricted through limitation of their access
to a variety of providers. It is within this trap that APNs
frequently find themselves. To flourish in the managed
care environment, APNs must market themselves to the
HP and to enrollees.

Chapter 9 Participation of the Advanced Practice Nurse in Health Plans and Quality Initiatives 157
care they provide. ANA and other nursing groups remain
committed to monitoring state and federal activities of
organized medicine to counteract their effectiveness. To the
extent that organized medical societies focus their efforts
on opposing or supporting legislation, even through the
use of exaggerated arguments and legislative strategies, the
major option available to nursing is to oppose those efforts
and to respond to them by ensuring that legislators and
the public hear the facts about APN practice.
APNs continue to be notably absent from HP provider
panels and from the national quality enterprise. This is
likely due, in part, to their predominantly employee status.
In moving to contracting independently with HPs, APNs
can take on full responsibility as managed care providers. In
addition, APNs can engage in the collection and reporting
of data, using measures related to the quality of care they
provide. Those data, in addition to informing nursing
practice, can help purchasers and consumers decide where
to look for high-quality, effective, efficient care. Using
data, APNs can mobilize consumer support for their
services, thereby increasing respect for themselves and on
behalf of nursing overall. It is up to individual APNs, to
professional nursing, to NQF, and to all who have interest
in the provision (or receipt) of high-quality health care to
advance quality in a collaborative, coordinated way. After
all, health-care quality really is an art . . . more like ballet,
than hockey (Crosby, 1979).
an environment in which APNs experience significant
barriers to their ability to practice. Strategies are needed
to unite the collaborative efforts of ANA, constituent
member associations, other national APN organizations,
individual APNs, and consumers. There is an ongoing
need to identify trends related to exclusionary behavior
and to develop an effective multipronged approach to
address anticompetitive policies and practices.
Nurses have looked to antitrust protections for relief
from practices that block their full participation in the
health-care market. CNMs and CRNAs used federal
antitrust laws to limit boycotts and expand their market
share. The Federal Trade Commission (FTC) has rendered
opinions that provide the foundation for anticompetitive
action by registered nurses. The Department of Justice
and the FTC have issued joint guidelines for antitrust
enforcement in the health-care industry that offer general
direction about those practices that are (and that are not)
likely to trigger action by these enforcement agencies.
Restrictive policies at the state level must be addressed
by a comprehensive state-based strategy to better define and
combat state-based anticompetitive behavior. Such strategies should include the state insurance commissions, state
boards of nursing, and consumer and regulatory entities to
enforce the law and to challenge anticompetitive activities.
It is crucial that nurses in general, and APNs in particular,
work to gain recognition for the high-quality, cost-effective

Public Policy and the Advanced
Practice Registered Nurse
Marie-Eileen Onieal
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Understand agenda setting and policy design.
Explain the interdependence of policy and practice.
Describe the importance of the political process in shaping health-care policy.
Integrate sociological, economic, and political perspectives into an understanding
of health policy issues.
Describe and discuss the impact of politics and economics on the health-care delivery system.
Analyze the current health-care policy environment and its effect on advanced
practice registered nurse (APRN) practice.
Participate in influencing political decisions that affect APRN practice.
Advocate for APRNs within the policy and health-care communities.
To begin a chapter on policy, one must first understand
there is much ambiguity regarding its definition. Derived
from the Greek word polis meaning city-state, a society is
characterized by a sense of community and obligation to
participate in its government, religious cults, defense, and
economic welfare and to obey its sacred and customary
laws (Merriam-Webster online; Encyclopdia Britannica Online). Policy is also defined as principles or actions
derived toward specific ends. In simple terms, policy is
the rational attempt to achieve common (often complex)
objectives. It is important to know that all policies reflect
the values of those making the policy.

Chapter 10 Public Policy and the Advanced Practice Registered Nurse 159
than a privilege, and the need for primary care providers
(PCPs) was increasing. APRNs quickly began to fill the
need for PCPs, especially in rural areas where poor and
low-income families, lacking access to health-care services,
were woefully underserved.
APRNs are a testament to the nursing leaders who
preceded them.Trailblazers such as Florence Nightingale,
Lillian Wald, and Margaret Sanger championed the cause
of improved health care, especially for the disenfranchised
(Piren & Reinhard, 2009). Following in the footsteps of
those pioneers, Loretta Ford blazed the trail for the nurse
practitioner (NP) role to meet the health-care needs of
society. In 1965 Loretta Ford, EdD, RN, PNP, and
Henry Silver, MD, saw the need for better access to care
for children and launched the first program to educate
nurses in the advanced practice role. From that seed, the
profession grew and brought with it a new paradigm in
health care. The birth of the advanced nursing practice
role was instrumental in solving the health-care access
crises faced in the mid 1960s.
Throughout nursing history people considered nurses
as a group set apart to serve society (Sellew & Neusse,
1951, p. 391). The public also looked to nurses for community service and leadership (Dock & Stewart, 1929,
p. 361), leaving nurses with a moral obligation to society.
That obligation constituted a type of social contract that,
in addition to assurance of competence, concern for the
well-being of patients, integrity, and accountability, is the
responsibility to participate in formulating public policy
that affects not only the scope of practice for APRNs but
also the access to APRNs as PCPs and integral members
of the health-care team.
Policy and the APRN
In 1985 Senator Edward Kennedy astutely noted that
Nurses are Americas largest group of health professionals,
but they have never played their proportionate role in
helping to shape health policy, even though that policy
profoundly affects them as both health providers and
consumer (Mason & Talbot, 1985, p. xxi). He was a
tireless supporter of, and endless believer that, all Americans deserved the opportunity to have access to health
care. More than that, Senator Kennedy understood and
supported the roles played by nurses, specifically APRNs,
in making that access a reality.
Public policy is about communities trying to achieve
something as a community despite any conflicts within the
goals (Stone, 1997). Itencompasses the choices that society
as a whole, or a segment of society, makes regarding those
goals and priorities, which can be a public interest. In
that construct, there can be two sides; one of self-interest
and one of public spirit. Regardless, the underpinning
of the policy is for the good, and in some instances the
protection, of the community.
Public policy is the group of authoritative decisions
made in the legislative, executive, or judicial branches of
government at either the state or federal level within the
jurisdiction of those entities. The decisions, intended to
direct or influence the actions or behaviors of others, can
be laws, rules, or operational criteria. Public policy is the
governments solution to resolve the problems of society
(Harrington & Estes, 2008). A component of the policy
making process is the formulation of the problem and
the identification of possiblesolutions. Theselection of the
solution, based on an analysis of alternatives, forms the
Advanced nursing practice is broadly defined by the American Association of Colleges of Nursing (AACN, 2004) as
any form of nursing intervention that influences health
care outcomes for individuals or populations, including
the direct care of individual patients, management of care
for individuals and populations, administration of nursing
and health care organizations, and the development and
implementation of health policy (p. 2). The advanced
practiceregistered nurse(APRN) title consists of four roles:
certified nurse practitioner (CNP), certified nurse-midwife
(CNM), certified registered nurse anesthetist (CRNA),
and clinical nurse specialist (CNS) (National Council of
State Boards of Nursing [NCSBN], 2008).
The history of the APRN can be traced back to the mid
20th century, a time when barriers of access to health care
were increasing. The combination of the decrease in the
number of nurses and physicians being deployed to Viet
Nam and the growth in population stressed the health-care
provider community. At the same time, Americans were
clamoring for health care to be a fundamental right rather

160 Unit 2 The Practice Environment
Responsibility for working toward meeting the health-care
needs of society lies with every APRN. As a member of
the profession, every APRN has an ethical and moral
obligation (the social contract) to influence both public
and health policy so that the health of the public is both
protected and promoted. Far too often in the past, the
idea of becoming politically active has been frightening
to many APRNs. Perhaps they lacked the confidence to
get involved or confidence regarding how to advocate at
the policy level, or they preferred to stay on the sidelines.
Today, with health policy and leadership essential components in all nursing education, not just APRN education,
the barriers to becoming an active participant in policy
development are decreasing. It is imperative for APRNs
to recognize and undertake the responsibility of the
potential to contribute to the development of health policy
through political action, thus meeting the obligations of
the social contract.
APRNs have long used the policy making process when
reaching decisionsperhaps not as a formal method, but
surely informally as the process of gathering the alternative
options for solving the problems at hand, such as going
through a sequence of mental operations to achieve the
desired outcome, weighing one option against another,
and choosing the one that most likely will achieve the
goal. In this policy making process, it is imperative that
the APRNs be participants in those processes that occur
in the public arenas and impact the practice of APRNs.
It is equally imperative that the APRN role is represented
at every policy tableit is often said, If you are not at
the table you are on the menu. Being involved in the
discussion of alternatives gives the APRN a voice and
ensures that voice is heard on issues in state and national
legislation that potentially affect APRNs, their patients,
or access to health-care services. Those issues that affect
the future development of the profession are of specific
concern, specifically the requirement in some states that
APRNs practicein collaboration with a licensed physician.
Professional nursing organizations worldwide have
mandates and processes for nurses to engage at some level
in policy development. Provision 7 of the 2015 Code of
Ethics for Nurses with Interpretive Statements (American
Nurses Association [ANA], 2015) requires nurses, in all
roles and settings, to advancethe profession through research
and scholarly inquiry, professional standards development,
and the generation of both nursing and health policy.
The latter underscores the nurses responsibility to lead or
serve on institution, local, state, regional, or global civic
or organizational policy making committees (Lachman,
Swanson, & Windland-Brown, 2015). As a component of
that, APRNs must act on their responsibility to be leaders,
serving and mentoring others on policy committees in their
practice settings, and serve as health-care consultants to
local, regional, and state representatives.
Entities that credential APRN programs, or provide
guidelines for those programs, also have mandates that
the curricula include content that provides for the APRN
to become competent in the policy arena. Those bodies
(National Organization of Nurse Practitioner Faculties
[NONPF], AACN, and Commission on Collegiate Nursing
Education [CCNE]) acknowledge that political activism
and a commitment to policy development are central
elements of professional nursing practice (Ehrenreich,
2002). Engagement in the process of policy development
includes the ability to influence policy makers to improve
health-care delivery and outcomes. An essential component of that engagement is that APRNs understand the
relevant state legislative agenda and how it affects their
scope of practice.
Political competence is requisite within nursing to
(a)intervenein the broad socioeconomic and environmental
determinants of health, (b) intervene effectively in a
culturally diverse society, (c) partner in development of a
humane health-care system, and (d) bring nursings values
to policy discussions (Warner, 2003). In 2007, the ICN
described the APRNs policy making role and asserted that
APRNs should contribute to public policy pertaining to
the determinants of health (Carnegie & Kiger, 2009).
One reason APRNs need to assume a political role is a shift
in focus from the individual as patient to communities
experiencing health inequalities. APRNs must get involved
at the political level and where advocacy and citizenship
are located within a community role.
APRNs must advocate for their autonomy, educate
legislators on both the economic and societal value of care
provided by APRNs, and strive to convince legislators to
remove barriers to their practice. APRNs need to be more
involved in policy making, which influences the delivery
of care. Professional associations have traditionally fulfilled
key roles by acting on behalf of the professions individual
members to establish a contract with society and influence
health-care policy (Dollinger, 2000, p. 28); however, it is

Chapter 10 Public Policy and the Advanced Practice Registered Nurse 161
bodies to achieve a sound model and continued communication with the goal of increasing the clarity and
standardization of APRN regulation. In addition, the
group recognized the need to continuously and regularly
discuss issues related to nursing education, practice, and
credentialing. The model must remain a living document
that can be easily updated to respond to changing societal
needs and the desire for consumers to have unfettered
access to care provided by APRNs. In addition, the model
provides a formal, ongoing communication mechanism
that allows transparent and aligned communication
among the key stakeholders having an interest in advanced
practice nursing.
Implementation of the recommendations for an APRN
Regulatory Model was intended to occur incrementally
(NCSBN, 2008) and be fully implemented by 2015. The
model, now 9 years postendorsement, has been enacted
in more than 40% of states. Those 21 states have adopted
full practice authority licensure and practice laws for
APRNs. Under these laws, APRNs practice independently
and are accountable for recognizing limits of knowledge and experience, planning for the management of
situations beyond [their] expertise; and for consulting
with or referring patients to other health care providers
as appropriate (Fairman, Rowe, Hassmiller, & Shalala,
2011). The enactment of major Consensus Modelelements
by a sufficient number of states now should create the
momentum to encourage the remaining states to align.
Continued attention and persistence along the Consensus
Model elements demonstrates that full practice authority
removes barriers to APRN practice.
The societal benefit of implementing full practice
authority for APRNs is in providing patients with full and
direct access to all the services that APRNs are prepared to
provide. Full practice authority for APRNs is supported
in reports from several entities. Along with the Institute
of Medicine (IOM), which specifically targets regulatory
barriers, organizations such as the Macy Foundation
support broader scope-of-practice boundaries. One of
the largest consumer groups, the AARP (formerly the
American Association of Retired Persons), also supports
an expanded role for APRNs in primary care as well as
care provided in secondary and tertiary settings. From
an economic benefit standpoint, strengthening access to
primary care by increasing use of APRNs expands the
availability of primary care at a lower price. In addition,
incumbent upon the individual APRN to take an active
role in advocating for those policies that promote access,
equity, quality, and cost, all of which require removal of
barriers to practice.
APRN Regulation: The Consensus Model
In July 2008 the Consensus Model for APRN Regulation
was published. The rationale for the APRN Consensus
Model was to align the processes of license, accreditation, certification, and education to alleviate concerns
about patient safety in light of the increasing numbers
of APRNs performing in roles with constantly changing
The model is the product of many years of substantial work conducted by the Advanced Practice Nursing
Consensus Work Group and the National Council of
State Boards of Nursing (NCSBN) APRN Committee.
The task of the committee was to develop and validate
nationally recognized educational standards, nationally
recognized role competencies, and nationally recognized
specialty competencies. The members of the consensus
group represented 41 nursing organizations. The document
defines APRN practice, describes the APRN regulatory
model, identifies the titles to be used, defines specialty,
describes the emergence of new roles and population foci,
and presents strategies for implementation.
The Consensus Model for APRN Regulation wasendorsed
by those nursing organizations that participated in the
APRN Consensus Work Group and the APRN Joint
Dialogue Group with unanimous agreement on most of
the recommendations (2008). It includes the following
essential elements: licensure, accreditation, certification,
and education (LACE).
Licensure is the granting of authority to practice.
Accreditation is the formal review and approval by a
recognized agency ofeducational degree or certification
programs in nursing or nursing-related programs.
Certification is the formal recognition of the knowledge,
skills, and experience demonstrated by the achievement
of standards identified by the profession.
Education is theformal preparation of APRNs in graduate
degree-granting or postgraduate certificate programs.
The recommendations within the Consensus Model reflect
a necessity and intent of collaboration among regulatory

162 Unit 2 The Practice Environment
of the Medicare and Medicaid programs. Because of these
laws, the United States has the opportunity to transform
its health-care system and provide higher quality, safer,
more affordable, and more accessible care than ever
before. That said, fulfilling the vision of the ACA requires
a transformation of many aspects of our health-care system, particularly those pertaining to APRNs (Cella &
King-Jensen, 2011).
Although the enactment of the ACA has improved
access to the services provided by APRNs, barriers to full
implementation still exist. Case in point: APRNs have
been authorized Part B Medicare providers since 1998.
Despite this recognition, APRNs with patients who need
home health-care services still have to locate a physician
to certify that the APRN has conducted the required
face-to-face certification examination to documenteligibility
for care. APRNs can provide face-to-face assessments of
the patients needs, yet the requirement that a physician
document the encounter still exists. Such requirements
increase costs and delay necessary care, which is contrary
to the intent of these authorizations.
Since the full implementation of the ACA, 18 million
uninsured people have gained health coverage (Assistant
Secretary for Planning and Evaluation [ASPE], 2015).
The ACA has also improved access to health-care services
provided by NPs evidenced by the nondiscrimination
provision acknowledging APRNs as PCPs. Having
access to a regular source of primary care is associated
with more effective provision of preventive services and
better management of chronic disease. The Department
of Health and Human Services (HHS) estimates that
another 10.5 million uninsured Americans are eligible
for coverage through the public insurance exchanges, and
a push will be made to enroll them (Pear, 2015). These
factors and an aging and growing population contribute
to the demand for primary care. A shortage of PCPs, acute
in some areas of the country, is expected to significantly
grow in the years ahead. These are solid reasons to support
full-practice authority for APRNs with favorable and fair
reimbursement policies.
According to the IOMs landmark 2011 report, The
Future of Nursing: Leading Change, Advancing Health, the
ability of APRNs to meet the nations health-care needs
and practice to the full extent of their education and
clinical preparation continues to be limited by significant
barriers in federal law and regulation. Further, the report
it has the potential to decrease the incidence of sequelae
related to illness and diseasethat has gone untreated because
of access barriers. In Massachusetts alone, research shows
that allowing APRNs to practice at their full capacity
demonstrated a savings of $4.2 billion to $8.4 billion
over 10 years and that greater use of retail clinics staffed
primarily by APRNs could save an additional $6 billion
(Eibner et al, 2009).
Since the 1960s APRNs have enabled the expansion of
community health centers. By 2011, there were 7,354 sites
throughout the country that provided care for more than
16 million people (Aiken, 2011). In addition, millions of
American families received care at more than 1,100 retail
clinics staffed primarily by APRNs, easing the burden
on emergency departments (EDs). Moreover, several
health-care reform initiatives are contingent on APRNs
filling a range of new roles in primary care, prevention,
and care coordination (Aiken, 2011).
The Affordable Care Act and the APRN
The ability to access health-care services, regardless of
setting, is a longstanding concern for both consumers and
government. The IOM Primary Care Reports consistently
define accessibility as a cornerstone of care (IOM, 1978,
1993, 1996). The 2000 IOM report, Americas Health
Care Safety Net: Intact but Endangered, recognizes that
the United States fails to provide timely and adequate
access to health-care services for vulnerable populations.
In March 2010 President Obama signed comprehensive
health reform, the Patient Protection and Affordable Care
Act (ACA), into law. The law was designed to increase the
number of Americans covered by health insurance and
decrease the cost of health care. Its enactment was the
end of decades of attempts to enact comprehensive health
insurance. Many arguments have been made both before
and since criticizing the passage of this law, calling it too
costly and too quickly implemented without sufficient
planning or thought. Many have also denigrated the law
as being a step toward socialized medicine, whereas
others warn it encourages big government, a historically
distrusted approach to solving problems.
Improving access to affordable health insurance, and
by extension to care, is one of the main goals of the ACA.
With itsenactment came wide-ranging changes to the U.S.
health-care system not seen since the 1965 development

Chapter 10 Public Policy and the Advanced Practice Registered Nurse 163
professionals in redesigning health care in the United
States to achieve better health outcomes.
Within the constructs of practice authority are three
categories: full, reduced, and restricted. When the APRN
role was in its infancy, states with the most need for PCPs,
particularly those with large rural areas, were more apt to
mitigate statutory and regulatory barriers. A full practice
license allows the APRN to evaluate patients, diagnose,
order and interpret diagnostic tests, and initiate and manage
treatmentsincluding prescribing medications. This is
significant because in those states the right to full practice
is under the exclusive licensure authority of the state board
of nursing, not a regulated collaborative agreement with
another health discipline. This is the model recommended
by the IOM and the NCSBN. Today, across the 50 U.S.
states and territories, in only 21 states and Washington,
DC, do ARNPs have the authority to practice the full
extent of their preparation.
The Centers for Medicare and Medicaid Services (CMS)
regulate federally supported insurance programs. Medicare
recognizes unique attributes of the nursing profession,
including our adaptability, close proximity to patients,
and scientific understanding of care processes.
Healthy People 2020 outlines multiple determinants of
health; they include policymaking, social factors, health
services, individual behaviors, and biology and genetics
(HHS, 2011). APRNs are educated to address individuals in light of the social, economic, and environmental
factors that influence their healthin close keeping with
the recommendations of Healthy People 2020 (Pericak,
2011). Moreover, the evidence is compelling that APRNs
already have a significantly growing role in U.S. primary
care delivery (Pohl, Barksdale, & Werner, 2015).
State-to-State Comparisons
Different states have adopted different titles for the
advanced practice nurse, including NP, advanced nurse
practitioner (ANP), advanced registered nurse practitioner (ARNP), clinical nurse practitioner (CNP), and
registered nurse practitioner (RNP). Title variation by
state increases the confusion about the APRN role. This
inconsistency in titling has proven to be very confusing
to the public (Fotsch, 2016). Further, the differences in
how certification bodies direct APRNs to specify their
credential (i.e., FNP-C, CPNP) adds to the confusion.
There is no uniform model of regulation of APRNs across
states. Although the Consensus Model is a step toward
eliminating that lack of uniformity,each stateindependently
determines the APRN legal scope of practice, the roles
that are recognized, the criteria for entry into advanced
practice, and the certification examinations accepted for
entry-level competence assessment. These have all created
a significant barrier for APRNs to easily move from state
to state and has decreased access to care for patients.
The ACA recognizes APRNs as PCPs eligible to receive
grants and primary care bonus payments with no mention
of collaboration or supervision requirements (Figure 10.1).
Acknowledging APRNs as PCPs is paramount to the success of the ACA. Yet the barriers for APRNs to practice
independently continue. Restrictions on scope of practice
limits the supply of labor, restricts competition, and increases the cost of services. Utilizing APRNs to the full
extent of their knowledge and competence extends the
paradigm of health care. APRNs must be acknowledged
as full partners with physicians and other health-care
Yes: 42 states
(May include recognition in Medicaid or in other
insurance laws)
No: not explicitly recognized:
8 states + DC
*Note: Not all states grant full-practice authority to ARNPs.
Figure 10.1 Recognition of ARNPs as primary care providers
in state law.*

164 Unit 2 The Practice Environment
provide. Moreover, reduced Medicare reimbursement
for APRN services, which is already low, makes financial
solvency difficult.
In July 2016 there were 683 bills in thelegislatures of the
50 states and territories that directly affected APRN-delivered
care. An additional 112 bills dealt directly with primary
care. Within each bill was a recommendation to remove
barriers that make it difficult for APRNs to serve as PCPs
and leaders of patient-centered medical homes or other
models of primary care delivery. Those barriers included
reimbursement policies, scope of practice and controlled
substance prescriptive authority, required supervision
by another health-care provider, and discrimination by
individual health plans. State and national regulatory
and reimbursement policies must be amended to remove
barriers that make it difficult for NPs to serve as PCPs in
all models of care delivery.
Over the years, studies have consistently demonstrated
that APRNs provide high-quality, cost-effective health
care to patients of all ages in all walks of life in all settings.
It is crucial that reimbursement policies and systems be
re-engineered to reflect the true costs of care and promote
sustainable practice.
APRNs must be prepared to participate in the political
arena. They must stay focused on national and local contexts
in order to encourage policy development that includes
APRNs as key players in the delivery of quality care to
the American public. It is a component of their social
contract to maintain accountability to their communities
to provide high-quality and affordable care.
It is easy to forget that the APRN role, established in
1965, is a relatively young one when compared with the
nursing profession as a whole. Despite its relative youth,
it has grown to become one of the most important roles
in the health-care community. APRNs have a rich history
of providing effective and essential care to patients and
the public. As we look to the future, we must celebrate
and draw upon our rich, if comparatively brief, history.
And all APRNs must continue to be active participants
in the political process.
provides insurancefor people age 65 or older, people under
age 65 with certain disabilities, and people of all ages with
end-stagerenal disease(permanent kidney failurerequiring
dialysis or a kidney transplant).
Medicaid provides health insurance coverage for our
nations most vulnerableindividuals and families. Medicaid,
a shared state and federal program, is regulated differently
than other insurance providers. Each state sets its own
guidelines for eligibility, services, and reimbursement
(CMS, 2016).
Effective January 1998, services provided by primary
care ARNPs became reimbursable by Medicare. Although the reimbursement rate was 5% lower than that
for physicians, this was a breakthrough in mitigating
barriers of access to care based on payment. Despite
this achievement, challenges to reimbursement for
APRNs continue to exist. In addition to Medicare and
Medicaid, many third-party payers, whether a managed
care organization or other commercial insurer, recognize
APRNs as qualified health-care providers. However,
differences in the reimbursement and coverage policies
can be extensive. This conundrum is compounded by
the restrictions of Medicaid and other private insurers,
as well as restrictions within states and policies related
to direct reimbursement and supervisory requirements
by another health-care provider. Each entity has its own
set of billing criteria and within them exist challenges
for the APRN.
It is imperative that reimbursement policies for all
payers be updated to guarantee that APRNs are eligible
to participate and are directly accessible to patients. Moreover, reimbursement should reflect true costs associated
with providing quality care and promote the effective and
efficient utilization of the health-care provider workforce
(Nurse Practitioner Roundtable, 2010). The IOM (2011)
echoes the sentiment of the APRN community in their
recommendations that all third-party payers participate
in direct reimbursement for APRNs who provide services
within their scope of practice.
The requirement for collaborative agreements in
many states limits the ability of APRNs to have a
self-governing license. Lack of consistent reimbursement
across states has kept APRNs largely invisible and minimizes the quantity and quality of care they currently

Resource Management
Eileen Flaherty, Antigone Grasso, and Cindy Aiena*
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Interpret profit and loss (P&L) statements.
Explain the drivers of operating revenue.
Distinguish relationships between reimbursement and payer mix.
Describe types of expenses: salary, nonsalary, and depreciation.
Understand fundamental considerations in creating a budget.
Recommend strategies to maximize revenue.
Illustrate cost containment strategies.
Demonstrate the impact APRN practice can have on revenue generation and expenditure of resources.
In any setting, the advanced practice registered nurse
(APRN) influences and is influenced by the environment of an organization. The organization provides the
structure in which the APRNs clinical practice goals
will be pursued.
The underlying assumption for any organization is
that its reason to exist is to produce some product or
service (output) that is of value. The corollary assumptions
are that, because the output is of value, it will generate
revenue and that the revenue generated will both cover
the costs of the resources expended (input) and provide
some level of profit. Profit is necessary to ensure the
continued viability of the organization, for example, to
upgrade existing facilities, to replace outdated equipment,
to expand services or to add new programs, and, in forprofit organizations, to provide a return for investors or
owners and encourage continued investment. If this does
*Earlier versions of this chapter were authored by Christina Graf. not occur, the organization will not survive. To succeed

166 Unit 2 The Practice Environment
specifies that revenues are recognized when services are
provided and expenses are reported as resources are used.
The matching principle requires that, when revenues are
reported, the associated or matching expenses arereported.
Thus, revenues reported for activities within a particular
cost center are matched to the expenses generated in
producing those revenues and reflect the activity and
resource utilization that occurred in that reporting period
regardless of when actual monies for services are received
or bills for resources are paid.
Revenue refers to the income that an organization receives
and can be broken into two main categories: operating and
nonoperating. Operating revenueincludes theincomefrom
the primary activities of the organization. For a hospital,
this might include patient revenue, retail activities (retail
pharmacies, parking, and cafeteria), and research-related
income. Nonoperating revenue is from other sources
that benefit the organization through activities such as
investments and philanthropy.
Operating Revenue
Revenue that is generated primarily from the day-to-day
activities of the organization is termed operating revenue.
In health-care organizations, the majority of the operating
revenue is related to patient or client services rendered and
may come from a variety of payers: the federal government
(Medicare, military, and veterans benefit programs), state
governments (Medicaid, health insurance exchanges,
and other state programs), other third-party payers (Blue
Cross/Blue Shield, health maintenance organizations,
fee-for-service insurance plans), or the recipient of the
service (self-pay).
Revenue or income refers to the monies received for
services provided and reflects the volume of output of the
organization. It is based on the price or charge allocated
to each specific service, activity, or item (also referred
to as gross patient service revenue). The organizations
charge master is a list of the prices charged, which are
intended to reflect the related costs plus some margin of
profit. However, charges are usually discounted or bundled under a global fee for most payers, entirely waived
in its mission, the organization must secure its financial
viability through appropriate prioritization of outcomes
and effective utilization of resources.
Organizational decisions can affect both the content and direction of the APRNs practice or in fact
determine to what extent APRNs are able to practice
within the organization. The absence of effective input
from clinicians can result in inappropriate or ineffective expectations of the clinician. Similarly, clinicians
decisions can generate unintended consequences that
undermine the health and strength of the organization.
Therefore, the APRN needs to understand the business
and financial structure and systems of the organization.
For example, how does the APRNs practice affect
revenue generation and expenditure of resources? To
what extent do business and fiscal policies enhance or
constrain clinical practice?
In accomplishing its mission, an organization engages
in a series of transactions that it tracks and manages
through its financial system(s). These transactions are
categorized according to the chart of accounts, a matrix
structure that organizes the transactions. One axis of
the matrix, the account codes, aggregates transactions
according to type (e.g., patient care revenue, salaries,
office supplies, maintenance contracts). The other axis,
the cost center, revenue center, or responsibility center,
aggregates transactions according to function and may
be identified by service line (cardiac center, cancer care
center), physical location (patient care unit, outpatient
clinic), or activity (blood bank, hemodialysis). The detailed designations in the chart of accounts are specific
to each organization and, as such, not only aggregate
transactions for better information and management
but also provide a picture of the organization and its
internal structure. The aggregated transactions are summarized in a statement of operations called the profit
and loss (P&L) or income and expense (I&E) statement
that also quantifies the operating margin or the gain
or loss (income minus expense) from operations. See
Figure 11.1.
Most health-care organizations use accrual accounting
in preparing financial statements. Accrual accounting

Chapter 11 Resource Management 167
for charitable care, or not collected from those who are
not expected to pay (bad debt). Therefore, charges are
not necessarily an accurate reflection of actual income
(net patient services revenue) from the service provided
(Gapenski, 2012).
Medicare revenues are determined not by charges on
individual services but by a prospective payment system
that allocates a fixed payment based on an episode of
care (Cleverly, Song, & Cleverly, 2011). The payment
is determined for inpatient episodes of care by the discharge diagnosis (diagnosis-related group [DRG]) and is
adjusted for variations in regional cost of living, urban
versus rural setting, and organizational involvement in
medical education. Except for some small amount of
adjustment for cost or length-of-stay outliers, the payment
to an organization for each DRG is constant regardless
of costs incurred. This prospective payment system is
not applicable to psychiatric and rehabilitation units or
(In Thousands of Dollars)
Gross Patient Services Revenue
Total Gross Patient Services Revenue
Deductions From Revenue
Contractual Allowances
Charity Care
Net Patient Services Revenue
Indirect Research Revenue
Other Operating Revenue
Total Operating Revenue
Salaries & Wages
Employee Benefits
Provision for Bad Debt
Total Operating Expense
Income (Loss) from Operations
Percentage of Total Revenue
Actual Budget Variance Variance
Note: Positive variances are favorable to budget; negative variances are unfavorable to budget.
Figure 11.1 Sample profit and loss (P&L) statement.

168 Unit 2 The Practice Environment
either the insurer determines that services provided did
not meet the eligibility requirements or a patient who was
expected to pay, in the form of copayments or deductibles,
defaults on those payments. As health-care costs increase
and all parties become more cost conscious, it becomes
important for providers to understand the rules and
meet all requirements to ensure they are getting paid for
all services rendered.
In addition to the many reimbursement methods that
currently exist, new payment mechanisms continue to
emerge. For example, many payers link quality measures,
outcomes, and utilization measures with reimbursement
incentives, also referred to as pay-for-performance and
shared savings programs. The intention of such programs
is to encourage cost management while maintaining continuous improvement in the quality of care delivered in
all health-care settings. In these arrangements, health-care
organizations and their providers are held accountable not
only for achieving defined quality standards to receive
full payment for services but also to decrease unnecessary
costs. Efforts around population health management and
medical homes are designed to improve performance on
these measures.
Another example of linking reimbursement to quality
is the October 2008 Centers for Medicare and Medicaid
Services (CMS) reimbursement policy that denies Medicare
reimbursement for specific hospital-acquired conditions
(HAC) that were not present on admission; this list of HACs
was further revised in 2013. See Box 11.1. CMS named
these medical errors never events because they should
never occur for any patient. As health-care organizations are
required to assume responsibility for the cost consequences
of preventable complications, moreemphasis is being placed
on the leadership role nurses can play in reducing medical
errors. More specifically, many of the never events such
as pressure ulcers and patient falls are nursing sensitive,
which further underscores the importance of high-quality
nursing care in protecting patients and securing revenues.
Intended to motivate hospitals to improve patient safety,
CMS has encouraged state Medicaid programs to follow
Medicares lead. In addition, many commercial health
plans are also seeking to implement payment plans that
will hold hospitals financially accountable for preventable
errors (Austin & Pronovost, 2015).
In addition to revenue from patient services, organizations may generate operating revenue from other
hospitals, childrens and cancer hospitals, or long-term
care facilities; these are reimbursed on a reasonable cost
basis, with some limits, for Medicare-eligible patients.
For outpatients, Medicare has developed a similar prospective payment system using ambulatory payment
classification groups (APCs) that aggregate services
that are similar clinically and with respect to resource
requirements. Medicare reimburses providers for services
based on prior fixed rates for the APCs (Rimler, Gale, &
Reede, 2015).
Medicaid and other state-sponsored payment programs
reflect not only the intent of the program but also the
economic and political environment of the state and
thus vary widely from state to state. The state determines
what will be covered and the level of reimbursement,
and may limit payments through global or flat-rate fees
for episodes of care, exclusion of certain services from
coverage, discounting of specific charges, or targeted
spending caps.
Many nongovernmental third-party payers negotiate
contracts directly with health-care organizations. These
contracts may include DRG-like prospective payment systems, discounted or adjusted rates, risk-sharing agreements
such as flat-rate payments per member per month for all
defined care needs, prior authorization requirements, or
other mechanisms that minimize the cost to the payer
and distance the revenue from the charge. These payers,
primarily managed care organizations, also include in their
reimbursement systems copays, specified dollar amounts
per episode of care, deductibles, and identified annual
dollar amounts or deductibles that are paid directly by
the consumer. Fee-for-service insurance payers typically
reimburse based on a negotiated percent of charges, but
there also may be copayments or deductibles, payment
ceilings, or service exclusions that shift the burden to the
insured. In any case, fee-for-service insurance provides
only a small percentage of the income of health-care
organizations. Even smaller is the proportion of self-pay
patients who are able to afford health care. The number
of uninsured, who have no access to federal, state, or
private coverage, generates charitable care for many
health-care organizations. However, it is important to
note that with the implementation of the Affordable
Care Act in 2010, the number of uninsured Americans
has gradually decreased. Other reductions to expected
revenue come in the form of denials and bad debt, where

Chapter 11 Resource Management 169
purpose or for the general purposes of the organization.
If the gift is in the form of an endowment, the principal
(the original amount of the gift) is invested and only the
interest income on the investment may be used.
Expenses are costs incurred in providing services. Wage
and salary expenses are the costs of personnel, the labor
costs required to deliver care and other activities within the
organization. Salaries are determined by the organization,
subject to regulation regarding minimum wage and fair
labor practices and, in some organizations, union contracts.
They include base wages plus any differentials, premiums,
bonuses, or other monetary rewards. Fringe benefits fall
into two categories: those mandated by law, such as unemployment insurance and workers compensation, and
those specific to the organization, such as health insurance
and pension benefits. Other benefits that incur costs are
related to the organizations personnel policies regarding
sick, vacation, holiday, and other paid time off. In addition
to the obvious salary cost for the employee receiving paid
time off, there is an additional expense if the work of that
employee must be covered by another individual. If the
work of the employee is not fully covered, there may be a
productivity cost associated with volume or revenue that is
not realized. In a practice, if practitioners are functioning
at efficient levels, the absence of one practitioner on a paid
leave will result either in loss of revenue for patients not
seen or increased costs for a temporary replacement for
the practitioner. Note that this relates to paid absence.
Unpaid absence leaves unspent wages available to support a temporary replacement or provides a cost offset to
unrealized volume and associated revenue.
Nonsalary expenses are those nonpersonnel costs for
consumable supplies, minor equipment, and related activities used in the delivery of service. Some are directly
related to patient care activities, such as medical supplies,
drugs, and blood products. Others are related to supports
for the care process (officesupplies, telephone charges), the
environment (maintenance contracts, utilities), personnel
(seminar registration, consultation fees), or interest on loans.
Another type of expense is depreciation or the recognition of the cost of capital assets (Gapenski, 2012). Capital
expense refers to major investments in durable assets, such
day-to-day activities in areas such as the parking garage
or the cafeteria, or indirect research revenue, the overhead
received from research sponsors for providing facilities and
administrativesupport for research projects.Total operating
revenue is net patient services revenue plus other operating
and research revenue and reflects the total reimbursement
in actual monies that the organization expects to receive
from operations.
Nonoperating Revenue
The organization may also generate nonoperating revenue
that is not tied directly to the services provided. Nonoperating revenue is managed and reported separately from
operating revenue. This revenue is not included when reviewing the financial implications of day-to-day operations
nor included in the operating margin. Interest income may
be generated on cash or investments. Gifts or donations
may be given to a not-for-profit organization for a specific
Box 11.1
Hospital-Acquired Conditions (HAC) List
Foreign object retained after surgery
Air embolism
Blood incompatibility
Stage III and IV pressure ulcers
Falls and trauma
Manifestations of poor glycemic control
Catheter-associated urinary tract infection (UTI)
Vascular catheter-associated infection
Surgical site infection, mediastinitis, following
coronary artery bypass graft (CABG)
Surgical site infection following bariatric surgery
for obesity
Surgical site infection following certain orthopedic procedures
Surgical site infection following cardiac implantable electronic device (CIED)
Deep vein thrombosis (DVT)/pulmonary embolism
(PE) following certain orthopedic procedures
Iatrogenic pneumothorax with venous catheterization
Hospital-Acquired Conditions. Centers for Medicare and Medicaid
Services, 2016.

170 Unit 2 The Practice Environment
Variable Versus Fixed Costs
Variable costs are those related to the volume of activity
and fluctuate based on changes in volume. Fixed costs
are those that remain constant regardless of fluctuations
in volume. In personnel, the staff nurses may be considered variablemore are needed when the unit is at 90%
occupancy than when it is at 75% occupancywhereas
the clinical nurse specialist (CNS) and nurse leader are
fixedone allocated to the unit(s) regardless of the number
of patients. Similarly, medical supply expense is variable
based on patient volume and acuity whereas maintenance
contract expenses may be fixed based on the terms of the
contract and not driven by volume. Some expenses may be
step-variable, that is, fixed over a short range and variable
over a longer range. For example, one secretary may be
sufficient for a practice with up to four clinicians, but a
second secretary may be required if an additional clinician
enters the practice. In that case, the number of secretaries
is fixed at two unless the number of clinicians increases
beyond eight. In general, all costs that are fixed in the
short run are variable in the longer run. See Figure 11.2.
Direct Versus Indirect Costs
Direct costs are those related to the process of producing
a product or service. Indirect costs are those incurred in
supporting that process. In practice, the identification
as facilities, equipment, and machinery. Capital assets
are expected to have a value and useful life significantly
greater than that of minor equipment. The threshold for
determining what is capitalized is set by the organization
and usually describes both a monetary value and an expected life span. For example, the threshold for capital
might be equipment that costs more than $5,000 and has
a useful life greater than 3 years. Under these guidelines,
neither a $100 intravenous (IV) pole(monetary threshold)
nor $1,000 worth of instructional videotapes (life span
threshold) would be considered capital.
Because capital assets are expected to be used over an
extended period of time, their full purchase price does not
appear as an operational expense at the time of purchase.
Rather, in each reporting period for the duration of its
useful life, the I&E report reflects the capital depreciation
or use of the capital asset during the period. For example,
if a capital purchase of $12,000 is expected to have a useful
life of 10 years, one-tenth of its value is estimated to be
used each year. Therefore, the financial statement would
report depreciation of $1,200 per year or $100 per month.
A variety of cost concepts are relevant in understanding
resource management and utilized when making decisions
about long-term planning (Cleverly et al, 2011).
Fixed Costs Variable Costs Step-Variable Costs
Figure 11.2 Fixed versus variable costs.

Chapter 11 Resource Management 171
necessary to provide additional staff hours to cover those
in class, these replacement costs are also included in the
incremental costs. The CNSs time in preparation and
teaching, and the facilities or space in which the classes
are taught, would not be considered incremental costs
becauseif the classes were not giventhe CNSs salary
and the cost of maintaining the facilities would still be
incurred. The incremental costs would be calculated for
the number of students and programs presented over a
given period of time.
Opportunity cost measures the loss of the effect of
the next best alternative use of the resources allocated to
a particular use. If the previously described program is
approved for implementation, what activity will the CNS
forego to implement the program? If the participants are
taking the course during their regular working hours and
replacement is not required, what will they not be doing
that might otherwise have been done? If the incremental
resources were not allocated to this program, how would
they be used instead? The answers to these questions describe
the opportunity costs. Identification and quantification
of opportunity costs can provide important information
in setting priorities and analyzing alternatives (Finkler,
Jones, & Kovner, 2013).
Effective management presumes that an organization, in
planning for its continuing existence, is able to describe
and project the level of activity or production of services
or products it will experience and anticipate the resources
that will be required for that level of activity. The budget
is the translation of that plan into quantities and dollars.
The conceptual plan on which the budget is based may
describe the projections for the entire organization or for
some particular sector or activity and will determine the
scope of the budget including the time frame and the
level of detail.
Types of Budgets
Strategic planning is likely to be translated into a
long-range budget that addresses the direction of the
organization over the next 3 to 5 years or more. For this
type of budget, the projections of volume and resources
of expenses as direct or indirect depends on the context.
In addressing an individual patient, caregiversnurses,
therapists, practitionerswould be considered direct
whereas the leadership and support staffsecretaries,
CNS, or nurse leaderwould be considered indirect. In
considering patient populations aggregated by clinical care
unit or practice, the entire staff of that unit or practice
could be considered direct whereas support departments
human resources, environmental services, financeare
identified as indirect.
Total Versus Unit Costs
Total cost is the aggregate cost incurred within a given
time period for all volume of activity in that time period.
Unit cost is the cost of one unit of volume, calculated
as the total cost divided by the total units of volume.
Marginal cost is the additional cost required to produce
one more unit of volume. Because the total cost includes
both variable and fixed costs, economies of scale can be
achieved by increasing volumeand variable costson
the unchanged fixed cost base. For example, if a clinical
care unit can increase its occupancy, it will expend more
in variable direct care staff, but the cost per patient day
will decrease because the fixed costs are spread over more
patient days. Marginal cost for each additional patient
day is equal to the cost of the variable staff and supplies
for that patient day.
Incremental Versus Opportunity Costs
Incremental cost is the added cost incurred for an activity
that would not be expensed if that activity did not occur.
These costs may be variable or fixed, but they are essentially
new costs and do not include current costs that may be
redirected to the new activity. For example, if a CNS proposes to teach a new series of classes on pediatric cardiac
life support, incremental costs could include items such
as demonstration mannequins, audiovisual aids, books,
or other informational material and supplies for practical
application. These would all be incremental costs because
they would be incurred specifically for the purpose of
the program. The participants salaries are incremental
if they are paid beyond their usual or regular hours to
attend the program. If the program is to be given within
the participants regular working hours and it will be

172 Unit 2 The Practice Environment
from the profit generated from operations, or from loans,
which are also dependent on the organizations ability to
generate a profit from operations. Although the capital
budget may be prepared in yearly cycles, unlike the operating budget it is contained by the time frame of the
project rather than of the budget year. Thus, capital funds
may be allocated over several budget years for a particular
remodeling project or equipment replacement proposal,
and, unlike the operating budget, the funds will carry
over from year to year until the project is completed. The
capital budget is based on the plans and projections of the
organization and will address the facilities and equipment
needed to expand or upgrade services. These can include
the need for new or added clinical equipment such as cardiac monitors and ultrasound equipment; major software
(electronic medical record, provider order entry system);
and facilities improvement (renovation and remodeling).
The capital budget also needs to address the maintenance
needs of the organization and therefore will also includesuch
things as replacing existing equipment (such as ventilators
that have reached the end of their useful life) or facilities
maintenance (such as the heating, ventilation, and air
conditioning [HVAC] system). Finally, in preparing the
capital budget, it is important to consider any additional
operating costs that will be incurred because of the use of
the capital asset. For example, purchase of a monitoring
system, clearly a capital expense, can also generate operating costs in the form of replacement leads or probes,
batteries, or electrocardiogram (ECG) tracing paper, as
well as potentially salary costs if additional personnel hours
are required to review the monitors or file the tracings.
These expenses must be identified and incorporated in
the appropriate operating budget.
Frequently, organizations will consider initiating new
activities or expanding or changing existing ones. The
program budget is useful for this purpose. This type of
budget isolates one activity or program from all other
organizational activities to evaluate its effectiveness. The
basis for the program budget is the conceptual plan of
the program, or the program proposal, which also determines the time frame for the budget as well as the types
of expenses to be included (e.g., total costs, incremental
costs, opportunity costs). For example, a plan to expand
the hours of service for a medical urgent care clinic, using
existing facilities and equipment, may be adequately described in a program budget that looks only at incremental
will be at a high level, with estimations of revenue and
expense totals, but not at an extremely detailed level. The
major drivers of volume and resources will be described
and quantified and include items such as anticipated
changes in the patient mix, Medicare reimbursement
rates, treatment protocols, and inflationary cost increases
as well as incorporating any new major strategies such
as new programs and service lines or adding capacity.
Other factors will be estimated in the aggregate based
on current experience. The strategic plan and long-range
budget are schematic representations of the direction of
the organization rather than detailed blueprints. They
need to be reviewed and refreshed at regular intervals
to ensure that the organization continues to move in its
preferred direction and to respond to significant changes
in the health-care environment.
The operational budget, on the other hand, addresses
the detailed, day-to-day activity of the organization. This
type of budget looks in extensive detail at the projected
volume and resources and the associated revenue and
expense over a prescribed period of time. Usually the
operating budget is constructed for the fiscal year, the
organizations 12-month accounting cycle. The budget
describes anticipated activity based on the specific operational goals and plans of the organization for that period of
time and incorporates assumptions that will affect revenue
and expense, for example, changes in reimbursement or
inflationary increases in the cost of utilities or supplies.
The budget is prepared at the detailed level of account
within each cost or revenue center. Throughout the fiscal
year, actual performance is reported against the budget
for each month and cumulatively for the fiscal year to
date, and is reported for each cost or revenue center and
account code. However, each fiscal years operating budget
is independent of other years, that is, the positive or negative variance and the unspent budgeted monies from one
fiscal year are not carried over into the next. The operating
budget as a plan is valuable at the detailed level, the level
at which the work occurs and at which the activity and
resources must be managed. Aggregation of the budgeted
and actual revenue and expense at the organizational level
is also useful in providing overall direction and evaluation
for the organization as a whole.
The capital budget reflects the projected expense for
necessary facility improvement or acquisition of major
durable equipment. Funding for the capital budget comes

Chapter 11 Resource Management 173
to the average total cost. Before breakeven, the program
generates a loss for each admission. After breakeven,
the program generates net revenue for each admission.
See Figure 11.3.
Determination of the value of a program considers
more than the fiscal benefit, for example, opportunity
costs, social benefits and costs, or public relations value.
These factors are difficult to quantify and are therefore
not part of the program budget although they would be
contained in the program proposal. When a program budget is approved and implemented, it becomes part of the
operating budget for the implementation period and for
all subsequent years. However, it is also useful to evaluate
actual performance against the original program budget.
The projection of the cash budget is critical in thelife of
the organization. In the other types of budget, one of the
guiding principles is matching revenue to expenses, that
is, identifying the income for the activity that occurred in
a particular time period and the expenses related to that
activity that were incurred in that time period. Typically,
however, the actual receipt of the revenue and the payment
volume, resources, revenue, and expense for the current
fiscal year. Evaluation of the fiscal viability of the plan
would consider the extent to which incremental revenue
exceeds incremental expense. A plan to add a neonatal
intensive care unit in a service that previously provided
only routine and intermediate care would require a more
extensive program budget. The quantification of activity
would need to address potential volumeboth numbers
of neonates and clinical conditionsand probableincome
based on payer mix and reimbursement rates. Resource
requirements would include both capital expenditures for
facilities and major equipment and operational expenses
for personnel, supplies, minor equipment, utilities, and
overhead. Because of the time required to set up the
program and the anticipated ramp-up from opening to
full occupancy and utilization, the program plan would
cover an extended period of time. Fiscal estimates would
then need to be adjusted for the effect of inflation and
reimbursement changes. Evaluation of the program would
include a calculation of breakeven, that is, the point at
which the average total revenue for an admission is equal
= Profit
Fixed Cost
= Loss
Figure 11.3 Breakeven.

174 Unit 2 The Practice Environment
the significant activities that generate resource utilization,
and the elements that account for individual variation
within those drivers. For example, in the cancer infusion
unit, the primary measure may be the patient visit or the
therapeutic protocol. However, resource utilization may
vary based on whether this is a new or returning patient,
the length of the treatment, the patients response to
the therapy, or other issues or concerns that the patient
raises in the course of the visit. Although it may not be
possible to implement a workload measure that addresses
this variability in minute detail, it is possible to develop
measures that differentiate among patients and aggregate
those with similar resource requirements. For patients with
the same medical condition or undergoing the same therapeutic protocol, it may be possible to identify variations
in resource utilization based on age, stage of treatment,
functional level of activity, or other indicators. Using these
indicators as well as the primary volumeindicator of the visit
or protocol to describe patient populations, one can then
generate a more accurate projection of required personnel
and resources. The patients can be aggregated into groups
with similar resource requirements and the groups can be
weighted based on their average utilization relative to one
another. For example, in a particular practice, patients
receiving a specific intervention may require 15 minutes
of the clinicians time. However, a follow-up patient may
only require 10 minutes and a new patient may require
40 minutes. All patients, however, may require 5 minutes
for documentation and 5 minutes for follow-up. Theintervention patient, therefore, will consume 25 minutes of time
and the others 20 minutes and 50 minutes, respectively. If
the intervention patient is the benchmark and weighted at
1.0, the follow-up patient is weighted at 0.8 (20/25 (1.0))
and the new patient at 2.0 (50/25 (1.0)). Projecting visits
by patient type and applying the appropriate weights will
give a more accurate representation of the anticipated
workload than projecting the visits alone.
Similarly, although there has been a current focus on
considering mandated nursepatient ratios as a way of
ensuring adequate levels of care for patients, the ratios
ignore the differences among patients in their need for
nursing care. Identifying and measuring these nursing care
requirements, often referred to as patient acuity, can be
valuable information in managing and allocating nursing
resources.To do so, many acute-care settings have implemented patient classification systems as a methodology
of the expenses do not occur in the same time period.
Services are billed to third-party payers but the actual
revenue is received weeks or even months later. Supplies
are ordered, delivered, and used but the organization may
be billed days or weeks later and the bills may be paid on
a 30-, 60-, or 90-day payment cycle. Thus the revenue
and expense projections for a particular accounting cycle
in the operational budget may not reflect that cycles cash
flow, the actual cash coming into and going out of the
organization. The cash budget projects this flow over the
course of the fiscal year to ensure that there will be sufficient money in the organization to meet its obligations to
its employees for payment of salaries, to its suppliers for
payment of bills, and to its lenders for repayment of loans.
The Budgeting Process
The budget process is based on the conceptual plan,
goals, and objectives of the organization. The first step
in this process is the identification of the activity that
generates revenue and drives resource utilization. Within
the health-care system, there are typical volume statistics
that are used to quantify activity: admissions, discharges,
patient days, patient visits, procedures, and tests. In the
aggregate, however, these measures do not have the level
of precision needed for accurate prediction of revenue
and expenses. For purposes of predicting revenue, the
volume needs to be further defined to reflect the basis of
paymentby payer, by service, by product line, by DRG,
or by test or procedure code.
In contrast to revenue, different categories may be
needed for the purposes of predicting resource utilization.
DRG payments, for example, reflect medical condition
and interventions but do not as clearly reflect nursing care
needs of patients. Therefore, patients in the same DRG
and generating the same revenuemay have different
nursing care needs based on age, functional capabilities,
communication issues, or learning needs and thus generate
different levels of resource utilization. Payment systems
may be based on global fees (e.g., for normal pregnancy
and delivery) or on panels of patients (with the practice or
organization receiving a per patient per month payment
regardless of utilization of services) that are not reflective
of the individual variability in care needs and resource
requirements. It is necessary, therefore, to develop workload
measures that identify both the resource drivers, that is,

Chapter 11 Resource Management 175
possible to adjust the ratio. Current utilization relevant to
the change can be replaced with the anticipated utilization
and the ratio recalculated. Personnel and materials that are
not volume-driven are projected based on function and
analysis of current utilization. It is important to remember that all fixed resources become variable over the long
range, so it is important to look at the overall growth of
volume and workload to determine whether the level of
fixed resources continues to be sufficient.
When the projections of activity and resources have
been completed, they aretranslated into dollars. The simple
definition of total revenue is volume times price. However,
this must be adjusted for the payer and previously noted
contractual variations. Personnel expenses are based on
the salaries for the positions identified, including the cost
of differentials, premiums, and fringe benefits. Nonsalary
expenses will incorporate the existing cost for projected
materials and supplies adjusted for anticipated price increases and general inflation. The revenues and expenses
are totaled for the organization and the profit identified.
If there is no profitif the projected expense exceeds the
projected revenueor if the level of profit is not at the
level needed to achieve its fiscal goals (i.e., repayment
of debt, cash for capital expenditures), the organization
moves into the negotiation phase of the budget process.
This is the most difficult phase of the process because the
organization reviews its objectives and identifies steps to
be taken to resolve the issue. If the conceptual plan, goals,
and objectives for the budget were well thought out and
clearly stated at the outset, and the activity and resources
projected and quantified in relation to the plan, the negotiation phase is more likely to produce the budget plan
that is most beneficial for the organization and its mission.
Individual participants need to speak to the priorities and
requirements of specific departments or programs but also
evaluate them in relation to the requirements of other
areas and of the total organization.
The final stage of budgeting, and the most important
one, is implementation with evaluation. The plans developed
and refined through the rest of the processinitiatives,
practice changes, productivity improvements, and new or
expanded programsnow move into the operational life
of the organization.
Ongoing analysis identifies the extent to which actual
performance matches budget projections. The organization
can thus adjust as needed to unanticipated events that may
for quantifying nursing workload. Such systems, which
classify patients according to their needs for nursing care
(examples may include activities of daily living, medication
administration, physiological assessment or intervention,
communication support, medication preparation), enable
organizations to capture actual nursing workload and to
measure productivity by looking at therelationship between
nursing hours and workload over time. This approach can
provide a new dimension for managing resources beyond
the more simplistic but common measure of workload as
patient days and nursing hours per patient day (Finkler
et al, 2013).
Variable personnel and material resource requirements
are based on the projected workload volume. Using historical and current data, it is possible to construct a ratio of
resources to volumepersonnel hours per unit of work or
supplies per unit of work. The personnel hours will include
more than the direct care hours because there is indirect
time in the form of orientation for new staff, continuing
education for current staff, practice or departmental
meetings, teaching or precepting, or other organizational
activities that are a necessary part of the working year. In
addition, the personnel hours must reflect the impact of
benefit time because the individual on sick, holiday, or
vacation time is not available to attend to the workload.
Therefore, the personnel budget should be constructed
first on the ratio of direct care hours to workload, that is,
projected workload multiplied by the required hours per
unit of work. Indirect time is added to this based either
on a specific identification of the hours in the year that
will be allocated to these activities or on a current ratio
of indirect to direct care hours. For example, if clinicians
are currently spending an average of 36 hours per week
in direct patient activities and 4 hours per week in other
organizational activities, the 11% (4/36) needs to be
added to the calculated direct care hours to project the
total worked time. In the same way paid time off must
be added, calculated as the number of paid absent days
projected, or, if there is variability, current paid absent
days as a percent of total worked days.
Variable supplies can also be projected using a ratio of
current utilization to workload and projecting that same
ratio into the future. This approach assumes that future
utilization rates will mirror current ones. Changes in procedures, practices, or products could affect this, however,
and to the extent that those changes can be quantified, it is

176 Unit 2 The Practice Environment
The objective of financial management is to ensure that
the organization generates a profit that is sufficient to
maintain viability. The purpose of ongoing budget analysis is to determine the extent to which the organization
is meeting its targets over a given period of time or for a
particular program or activity and to correct or improve
its performance. Prudent management demands that the
organization maximizerevenue and contain costs to generate
profit or margin. Because both revenue and expenses are
initially generated primarily by the clinicians who are providing services, it is important that all clinicians, including
APRNs, understand and appreciate their contribution to
the fiscal soundness of the organization. In this context, it
is necessary to emphasize that fiscal considerations do not
drive the activities of the organization; it is the mission,
vision, and goals that determine direction and activities.
However, the financial structure provides the framework
for these activities and ensures the long-term viability of
the organization.
Maximizing Revenue
Revenues are a composite of volume (the number of
services provided) and price (income received for each
service provided). Effective organizations ensure that they
are generating as much income as possible. Fraudulent or
deceptive practices such as billing for services not provided
or providing unnecessary, expensive services clearly must
be avoided. However, ethical strategies for maximizing
revenues can be employed and can relate either to volume
issues or price issues.
Once an organizational activity passes the breakeven
pointthat is, the point at which revenue equals
expenseany additional volume will generate profit, all
else being equal. It is not surprising, therefore, that there
is so much emphasis, especially in practices, on how much
volume and revenue the individual practitioner generates.
In fact, in incentive practices within larger organizations,
financial rewards to practitioners are based on volume and
productivity. The measurement for identifying the individual practitioners contribution to the organization most
frequently is based on services billed. There is a desire, and
in many situationseven a demand, to demonstrate that the
individual clinician is generating enough revenue to cover
affect overall outcomes. The analysis of actual to projected
performance can be either fixed or flexible. Fixed budget
analysis compares actual revenue and expense to the calculated budget. Variances may befavorable to budgetbetter
than anticipated, that is, more revenue or less expenseor
unfavorable to budgetnot as good as anticipated, that
is, less revenue or more expense. It is also important to
understand the relationship between variances and the
overall impact to the hospital. For example, unfavorable
expense (such as increased staffing needs) may be related
to favorable revenue (higher patient census). Whether the
net of those two is favorable or unfavorable is key rather
than looking at one in isolation.
The limitation of this type of analysis is that it assumes
that the budget is static, unaffected by events or activities
that differ from budget assumptions. Flexible budget
analysis assumes a more dynamic budget, one in which
the new information is incorporated but maintains a
similar profile as the fixed budget. For example, staffing
is aligned with patient days in the fixed budget. If patient
days increase, it is expected that staffing will need to
change. A flexible budget maintains the relationship but
changes the budget to reflect the updated assumptions. As
an illustration, if six intensive care patients require four
nurses to care for them, a 3:2 patient-to-nurse ratio, nine
patients will require six nurses. On a fixed budget analysis,
the outputpatients servedis favorable to the budget
because there are more patients served, and presumably
more revenue, than projected. The input, however, is
unfavorable to the budget because there are more staff,
and presumably more expense, than projected. On a
flexible budget analysis, however, the 3:2 ratio of output
to input remains constant and the performance mirrors
the budget. If the nine patients require only five staff, the
ratio is 3:1.8 and the actual performance is favorable to
the budget on a flexible budget analysis even though the
output and expense are unfavorable to the budget on a
fixed analysis.
Clearly there is a place for both types of analysis in
evaluating actual performance against projected. As noted
in the discussion on cost concepts, although in the long
run all costs are variable, in the short run some costs are
variable and some are fixed. It is appropriate, therefore,
to use a fixed budget analysis to evaluate fixed costs and a
flexible budget analysis to evaluate variable costs (Finkler
et al, 2013).

Chapter 11 Resource Management 177
home visit programs; clinical pathways, case management,
and discharge planning programs; protocols to prevent
or promote early identification and treatment of complications of hospitalization such as nosocomial infections
or decubitus ulcers; or enhancing and expanding specific
services such as cardiology or oncology. APRNs in the
inpatient setting are uniquely positioned to influence
the efforts that affect volume. The APRNs can identify
approaches through study and analysis of existing systems
and research on best practices. They can have significant
input into the development of programs or protocols as
part of the multidisciplinary team. They may support the
implementation of changes through clinical evaluation,
consultation, and education. Finally, the APRNs may be
the most appropriate clinicians to manage the particular
program or activity.
Another mechanism to both increase revenue and reflect the level of services provided to a patient is to assure
that all services rendered are reflected on the bill with the
appropriate charge. Charge capture, or documenting and
charging for all billable services, can be a time-consuming
and administrative burden. However, accurately capturing
services not only improves reimbursement in the short
term but is also used by external agencies to impact reimbursement rates as well as calculate and publish quality and
acuity scores. Therefore, these additional services become
key to accurately reflecting the resource allocation for the
level of care that is being provided.
In addition to adding volume, revenue can be increased
by increasing reimbursement rates, the amount that the
organization is actually paid for each product or service.
However, this deceptively simple strategy is constrained
by regulatory, contractual, and economic considerations.
With the increasing trend in price transparency, public
opinion can also be a constraint. Actual reimbursement is
determined by government regulation, contract negotiation, or organizational definition. Government-regulated
reimbursement, such as for Medicare or Medicaid, is not
organization specific and, although concerted lobbying
efforts may have some impact, the potential for change
is limited. Organizations may present evidence that they
qualify for certain levels of reimbursement, for example,
for direct medical education benefits, but otherwise will
have little opportunity to affect payment levels. Reimbursement rates set through contract negotiations have a
greater potential for change but only during the period
salary and to contribute to profit. This has driven the very
appropriate efforts of nurse practitioners to secure billing
privileges. (See Chapter 6 for a more extensive discussion
of reimbursement issues.) However, this direct billing is not
available in all settings or through all payers. Even where
it is available, it may not be advantageous to the practice
for the nurse practitioner to bill directly. Regardless, it is
imperative to demonstrate the nurse practitioners contribution to the practice and to develop other measures of
volume and activity that can be used to evaluate the extent
to which the nurse practitioner is generating revenue.
These measures will be internal to the organization but
need to be regularly reported and evaluated in relation to
the overall success of the practice. Such measures will be
required as well in other circumstances where capitated or
managed care payment systems do not accurately reflect
through the billing system the volume of activity generated
for the practice by the nurse practitioner.
In other organizational settings, volume may be measured by charges generated for particular procedures,
tests, or services. This often leads clinicians to look for
new ways of charging for various activities, assuming that
this will maximize revenue and at the same time demonstrate their impact on revenue enhancement. Increasing
charges results in increased revenue potential from only a
relatively small percentage of payers because of the decline
of fee-for-service payment systems. Even this potential
may not be realized because of exclusions or payment
maximums set by the insurer.
Rather than focusing on charges, therefore, it is more
effective for APRNs to address issues with systems or practices that affect the volume of activity that is the basis for
payment. Under Medicares prospective payment system,
for example, payment is based on the number of patients
discharged within specific DRGs. If the length of stay per
discharge can be reduced, a greater volume of patients can
be admitted. What are the systems or practice issues that
increase the length of stay without adding therapeutic
value for the patient? What processes could occur before
admission or subsequent to discharge that would reduce
the length of stay? What services need to be provided
that will attract patients to the facility? Consideration
of these questions has led to a variety of approaches that
ultimately result in increased volume, for example, preadmission testing and evaluation with same-day admission
for surgical patients; telephone triage and follow-up or

178 Unit 2 The Practice Environment
practices or in ambulatory settings may be more directly
involved in identifying the appropriate codefor the services
rendered and must have a thorough understanding of the
coding system and the relationship of codes to services
provided. In other settings, coding may not be done by
the clinicians; rather, the codes are determined based
on information that the clinicians provide. The source
document for information for coding and billing is the
patients medical record. Documentation in the medical
record validates to the payer that the billed services were
provided and justifies the organizations claim for payment.
Inaccurate or incomplete documentation can lead to lost
revenue opportunities if the coders are unable to identify
all the services that can appropriately be charged (Finkler
et al, 2013).
Reimbursement is negatively affected by payer denials
and delays. Payers may deny reimbursement for services
not covered (excluded from reimbursement based on
the patients policy or the contractual agreement with
the organization) or for services not authorized (lacking
required prior approval from the payer or from a designated clinician). Payment may also be denied for services
deemed by the payer to beincompatible with the diagnosis,
medically unnecessary, or not adequately validated. Payers
who reimburse for hospital care on a per diem basis may
carve out days for payment denial if delays in scheduling
tests or consultations or in initiating discharge planning
and referrals result in additional, otherwise avoidable inpatient days. Billing challenges by payers may also result
in payment denials if supporting documentation does not
appear in the medical record that the billed services were
in fact rendered. Payers will audit records to validate that
billed services have been provided even after payments
have been made. If there is not adequate supporting
documentation, the organization is at risk not only for
repayments but also for additional financial penalties.
Inadequate documentation can lead to delays in billing
if additional information needs to be accumulated before
coding determinations can be made. Lack of compliance
with payers filing requirements may also result in denial
of payment. Claims that are questioned initially may be
resubmitted with additional evidence of the validity of
the claim; however, this involves rework and delays. In
addition, most payers have a filing limit, a defined period
of time in which a clean bill is presented in order for the
organization to be reimbursed at all. Delays in processing
of open contract negotiations. Because the negotiation
outcome needs to be satisfactory to both parties, and because both parties as business organizations are interested
in maximizing their profit, rate increases preferred by one
party may need to be tempered to be acceptable to the
other party. Charges defined by the organization can be
increased but the associated reimbursement rates may not
change based on contract terms related to price increases
(Finkler et al, 2013).
To maximize revenue, organizations must successfully
implement strategies to ensurethat the organization receives
all the revenue to which it is entitled under the existing
regulations, contractual obligations, and pricing structure.
Payment for services is contingent on the organizations
demonstrating that it has in fact provided therelevant service
or product. Different payers have varying requirements in
the way that claims are processed, the forms that are used,
and the specific data that are included. It is important,
therefore, to understand what is required, where it needs
to be recorded, and how it is presented to the payer.
All payers will require some level of detail on the services provided. This may be in the form of an itemized
statement of all billable charges for an episode of care or
the specification of relevant codes. Current Procedural
Terminology (CPT) and Resource-Based Relative Value
Scales (RBRVS) are coding systems developed by the
American Medical Association (AMA) and adapted by
the government to identify cost procedures and services
provided by clinicians. The International Classification of
Diseases, tenth modification (ICD-10), is developed by
the World Health Organization (WHO) and adapted
for use in the United States by the federal government.
It classifies diseases by system or category (e.g., blood
disorders, neoplasms, infectious diseases) and may be used
alone or in conjunction with other classification systems.
DRGs and APCs as discussed earlier are used for Medicare
claims for inpatient and outpatient hospital services and
for selected nongovernmental payers.* Certain payers
may also require evidence of preauthorization for specific
procedures or treatments or referral authorization for
specialty evaluation and management. Clinicians in many
*Case mix classifications are used for reimbursement in other sectors of
the health-care system by both governmental and private sector payers:
Home Health Resource Groups (HHRGs) and the Outcome and Assessment
Information Set (OASIS) in home care; the Minimum Data Set (MDS) and
Resource Utilization Groups (RUGs) for long-term care (Cleverly et al, 2011).

Chapter 11 Resource Management 179
term may generate additional expense in replacement,
rework, decreased customer satisfaction, and loss of
business. The desired alternative therefore is the least
costly alternative that is consistent with the mission and
goals of the organization.
Wage and salary expenses constitute a significant proportion of the costs in health-care organizations. Market
forces, regulatory requirements, and ethical personnel
management practices provide a framework for personnel expenditures. Within this framework, however, the
organization has flexibility in controlling expenses related
both to intensity and price of personnel resources used.
Intensity addresses the number of personnel or staff hours
required to manage a given patient population. The volume
and type of patients and their particular care needsthe
workload generated by that patient populationdrive the
personnel resources required. Measuring and managing
workload variability can provide opportunities for cost
containment. For example, scheduling staff in consideration of daily, weekly, or seasonal volume variations can
minimize expensive down time, as well as staff frustration resulting from inadequate staffing at busy times.
This requires an ongoing analysis of workload patterns
and trends to identify recurring variations. Unexpected
variations may be addressed with the use of overtime or
outside agency personnel. Both of these alternatives are
more expensive than the normal personnel costs for the
workload involved but are justifiable for unpredictable
workload variations. A consistent increase in activity,
however, requires a consistent plan for managing the
workload. If a practice is increasingly seeing patients later
than the usual scheduled hours and incurring overtime
and other increased costs because of it, it is worthwhile
to analyze the cause of the variation. System inefficiencies
may be delaying patient throughput and thus generating
additional unnecessary expenses that can be eliminated by
addressing the inefficiencies. Patterns of patient scheduling
may be changing, resulting in fewer visits scheduled earlier
in the day with more down time, suggesting that scheduled
staff hours need to be adjusted to accommodate patient
preferences. However, the variation may be the result of
a net increase in numbers of patients and visits. If this is
so, an analysis of the fiscal impact of the increased revenue and increased expense may demonstrate that adding
regular staff to cover the increased activity will be more
cost effective than continuing to use overtime.
and submitting bills and generating reimbursement,
whether related to incomplete documentation or because
of other systems issues, may also result in a lost income
opportunity for the organization. Money that the organization has received can be invested to generate interest
income. Money in accounts receivablethat is, income
that is anticipated but not yet receiveddoes not generate
any additional revenue for the organization.
The APRN in a practice setting that bills directly or
indirectly for the practitioners clinical activity needs a
clear understanding of the requirements and systems for
billingwhat can be billed, how it is processed, what
documentation is required, and time frames for billing.
By following through on these requirements, the APRN
is able to contribute directly to the timely and accurate
generation of income. In other settings, the APRN with
an understanding of the systems for reimbursement to
the organization contributes indirectly by providing and
promoting accurate and complete clinical documentation,
identifying systems issues that can generate delays in
the billing cycle, and supporting practices that enhance
the potential for maximizing revenue. For example, in the
inpatient setting, an APRN caring for a complex patient
with multiple comorbidities may be able to increase
reimbursement by assessing and documenting each of
the patient problems and interventions. Addressing the
patients DRG alone may limit reimbursement and not
acknowledgeexpenses generated from additional care needs.
Containing Costs
The volume of products or services produced drives
the total expenses of an organization. These costs are
a function both of intensity, or the extent of resources
required for each unit of volume, and of price, or the
cost to the organization of individual resource units.
Cost containment focuses on identifying the least costly
alternatives for supplying the personnel and materials
to produce these services or products. In addressing cost
containment, the organization evaluates the alternatives
not only in terms of total expenditures but also in relation
to potential impact on other aspects of the organization.
It is less costly to pay lower salaries, but if salaries are not
competitive in the market, costly vacancies and turnover
are likely to result. Inferior products that are less costly
to purchase may initially save money but in the long

180 Unit 2 The Practice Environment
experienced. In these circumstances, it can be less costly
to provide more skilled staff or more total staff at regular
salaries than to continue with overtime.
One approach addresses the mix of personnel and the
perceived advantages of reducing the numbers of professional staff and substituting less expensive unlicensed
assistive personnel (UAP). In some circumstances, this
may be effective; however, given the increasing acuity of
patients, such substitution may be counterproductive. In
acute care settings, forexample, patients arerequiring more
and more complex care, most of which cannot be delegated
to unlicensed staff. In addition, unlicensed staff increase
the workload of the professional staff because they assume
the added responsibility of directing and supervising the
UAP. For direct care, it may be less costly to have a higher
percentage of licensed staff and fewer total numbers than
to have a lower percentage of licensed staff and greater total
numbers. However, if the professional staff are responsible
for clerical or environmental tasks that can appropriately
be delegated to less costly personnel, providing those
supports can be an effective cost management approach.
Cost containment efforts can also address some of
the hidden costs in personnel management. Turnover
generates significant costs in recruiting, hiring, and orienting new personnel. Additional costs may be incurred
before the new employee is available if vacancies need
to be covered with overtime or more expensive outside
agency personnel. Programs to promote staff retention can
therefore be valuable in reducing turnover and its associated costs. Absenteeism can also be costly. Some level of
unanticipated absenteeism caused by illness is anticipated.
However, staff dissatisfaction, unmanageable workloads,
frequent excessive overtime requirements, or on-the-job
injuries can also contribute to high levels of absenteeism.
The cost is increased by the need for replacements, again
often with overtime or agency personnel. In addition,
costs to the organization for workers compensation are
directly related to the number of claims filed out of the
organization. Cost can be loweredand, potentially, staff
satisfaction and efficiency increasedby identifying and
addressing the factors contributing to absenteeism and
on-the-job injuries.
Similar to wages and salaries, the costs for supplies and
equipment are affected by market issues and regulatory
requirements, as well as by the volume and intensity of
services provided. Intensity in this context refers to the
Intensity of personnel resource utilization may also
be related to inefficient clinical practices. Routines,
procedures, and protocols that are based on tradition
(weve always done it this way) rather than on analysis
or research-based evidence may include unnecessary and
time-consuming activities that do not add value for desired
outcomes. How are medication administration times determined? What are the indicators that determine the level
of support for activities of daily living that each patient
requires? How frequently is it necessary to monitor vital
signs on postoperative patients? In what circumstances
are isolation precautions instituted and under what circumstances can they be discontinued? How effective are
the standard protocols for preparation for tests? Do the
standard patient teaching tools and programs result in
patient learning? Does the timing of drawing blood for
laboratory tests make sense in relation to the timing of
meals or medication administration or other treatments?
It may be instructive to evaluate the care that patients
with the same condition receive from different caregivers
or in different settings to determine whether differences
in practices result in differences in outcomes. In some
circumstances it may become evident that practices in
one setting are more resource intensive but do not add
value and can be adapted or eliminated.
For personnel resources, price is generally equated
with the cost of salaries and benefits. Containing costs
by reducing salaries or benefits is not often possible given
market conditions and the mobility of todays workforce.
It is possible, however, to ensure that the least costly
resources are used in any given situation. Overtime, for
example, is a very expensive way to staff. It is effective for
the occasional unanticipated increase in workload, but
extensive, continuous use of overtimerequires identification
of causes and alternative approaches.
In addition to volume increases, variability in workload
practices, or system inefficiencies, overtime may be related
to the capabilities of the staff involved. For example, inexperienced staff may need assistance with complex patient
issues or with development of organizational skills, or
experienced staff may be struggling with unfamiliar procedures or patient conditions. For these staff, education
and mentoring can promote developing competencies
that also increase efficiency and ultimately reduce the
overtime. The mix of staff may not be appropriate or the
total numbers of staff may not besufficient for the workload

Chapter 11 Resource Management 181
desired outcome or in reducing the potential for waste.
However, customization sometimes is more a matter of
individual clinicians preferences than of value added for
the patient. It is important, then, to evaluate the pros
and cons of standardization or customization in specific
circumstances to identify the least costly alternative. In
general, for products and processes that are used in a variety
of settings, standardization is preferable not only because
of the cost and productivity benefits but also because it
promotes consistency in providing services. Alternatives
to standardization should be undertaken only after
careful evaluation to ensure that the marginal benefit of
customizationthat is, the greater value that accrues
from the alternativeoutweighs the fiscal and operational
benefits of standardization.
As the previous discussions suggest, the appropriateness of measures to contain costs cannot be evaluated in
isolation from outcomes. Cost efficiency identifies the
minimum expenditure necessary to achieve an outcome.
Cost effectiveness identifies the minimum expenditure
necessary to achieve the outcome that is consistent with
the organizations mission and goals. Cost effectiveness,
therefore, incorporates an element of quality that is not
inherent in cost efficiency. Vacuum-assisted dressing for
postsurgical wound healing is significantly more expensive
than traditional dressings and would not be considered
cost efficient in a simple analysis that only addressed the
expense incurred for dressings until wound healing is
achieved. However, because it accelerates wound healing,
this intervention reduces the necessary length of hospitalization and extent of postsurgical follow-up. As such, it is
certainly cost effective, with benefits for both the patient
and the provider organization. In some circumstances
quality measures are not sufficiently developed to allow
precise measurement of costeffectiveness but, to theextent
that such measures are available or can be approximated,
they should be incorporated into analysis.
Cost effectiveness and cost efficiency are typically
analyzed using productivity measures or cost-benefit
analysis. Productivity is the relationship of inputs and
outputs, of resources used and products or services produced. Productivity relationships are expressed as ratios
and can focus either on the output or on the input.
Focus on the output addresses the question, What does
it take to produce the output? and is the ratio of input
to output, or resources divided by products or services.
number and kind of materials used for these services.
Cost containment looks at the least costly alternative to
providing the services. This can be addressed on two levels.
What are the specific supplies and equipment required for
a particular procedure, protocol, or service? In addition,
given that a specific item is required, which is the best
product to select among the alternatives available? In
relation to the first question, it is important to look at
the work and how it is accomplished. Materials assumed
to be necessary for the service provided may incorporate
items that are no longer necessary, do not add value, or are
useful only to a subset of the patients receiving the service.
With the materials necessary for a service identified,
the focus moves to selection of specific items among those
available. Product evaluation requires the involvement
of clinicians and others in the organization. Inherent in
the identification of an item as necessary for a particular
service is the description of its purpose and how it is to
be used. The primary concern in product evaluation is
how well the different products under review meet these
criteria. Other criteria also need to be considered such as
availability from the manufacturer and storage and maintenance requirements. A product that meets all clinical
criteria but cannot be produced and delivered on a timely
basis or has high maintenance (and associated down time)
potential may not be preferable to a less exotic but more
available and reliable product.
Prices for materials and supplies are negotiated with
vendors. Organizations may identify cost containment
opportunities in the course of these negotiations through
volume discounts or as part of purchasing groups. This
raises the issue of managing the tension between standardization and customization. Frequently, standardizing
supplies and equipment across service areas has significant
benefits in reducing the expense for purchasing, storing,
distributing, and using specific products. Although this
limits the range of products available to the clinician,
it also limits the time needed to become familiar with
the product, to develop ease in working with it, and to
use it in a variety of settings. It may, however, generate
some level of waste if, for example, a standardized pack
of supplies for a particular procedure contains items that
are used in most but not all situations. Customization,
on the other hand, matches the products specifically
to the individual patient, clinician, or situation. It can
have advantages in being more effective in achieving the

182 Unit 2 The Practice Environment
Cost-benefit analysis can identify theimpact of productivity improvements for the organization. Baseline analysis
of the net benefit (revenue minus expense) identifies the
profit margin. Productivity improvements are designed
to increase the profit margin by reducing the cost (but
maintaining consistent income) for each episode of care.
Moreover, decreasing length of stay has the added opportunity of creating capacity for additional volume. That
volume will generate additional income as well as additional expense. Assuming a consistent patient population,
if the cost per episode of care remains the same, the total
profit (income minus expense) will increase although the
profit per case remains the same. However, the cost per
episode of care may well decrease (as fixed costs are spread
over more cases) and enhance both the total profit and
the profit per case. Cost-benefit analysis can also identify
potential negative aspects of productivity improvement
efforts. Length-of-stay reductions must be consistent with
good clinical practice. Early discharge of patients may be
clinically premature and result in readmission of the patient
for continuation of care. Obviously, for the patient this is an
undesirable outcome and therefore could not be considered
cost effective. It cannot even be considered cost efficient
because many payers, particularly those who reimburse
on a cost per case, identify a time period after discharge
during which a readmission (for a condition related to
the original hospital stay) will be bridged to the original
admission. Additional expense will be incurred, but the
merged admissions will be considered as one episode for
the purposes of reimbursement and additional payment
will be denied (Finkler et al, 2013).
Reimbursement levels and the associated incentives to
contain costs are to a large extent payer driven. Reimbursement systems structured as fee-for-service include
little incentive for the provider organization to contain
costs. For a minority of payers reimbursement is generated by charges that are paid either in full or at some
negotiated percentage so increased utilization results in
increased revenue. The majority of payers, however, have
built into their reimbursement systems some incentives
for containing costs. Reimbursement at the per visit
rate is an incentive to reduce resource utilization and
Examples of productivity measures focusing on output
include hours per patient day, cost per procedure, and
visits per episode of care. Focus on input addresses the
question, How well are resources being used? and is
the ratio of output to input, or products or services divided by resources. Examples of productivity measures
focusing on input include visits per full-time equivalent
(FTE), tests per staff hour, and case hours per available
room hour. Productivity improves when output remains
constant and input decreases, or when output increases
and input stays constant. Productivity declines when
output remains constant and input increases, or when
output decreases and input stays constant. Productivity
ratios are of little value in isolation. Comparisons of
productivity ratios to targets set during the budgeting
process, to historical experience and trends, and to other
internal or external benchmarks are valuable for analysis
and identification of opportunities for increasing efficiency
and effectiveness.
Cost-benefit analysis is frequently used to evaluate a
particular program or project, or to compare programs,
approaches, or activities competing for resource allocation.
The analysis compares therevenues and expenses generated
by the program to determinethe net benefit (income minus
expense) or the ratio of benefits to costs (income divided
by expense). Determination of the value of the program
to the organization, however, is not determined exclusively
by analysis of the financial benefit. Benefits and costs that
are difficult to quantify, such as social benefits and costs,
opportunity costs, public relations value, and loss leader
opportunities, may be of considerable importance to the
organization and influence decisions to implement or
continue specific projects and programs.
Productivity is often focused on personnel resource utilization, but the concept also applies to material resources
and to the overall utilization of services. Length of stay
or number of days per inpatient stay, for example, can be
considered to be a productivity measurement that identifies
the relationship between the episode of care (output) and
the patient days, representing the aggregated resources
required to provide for that episode (input). Comparisons
are made among patients or groups of patients for a given
time period or across multiple time periods, and against
internal and external benchmarks. Productivity improves
if the length of stay (and associated expense) decreases for
the same level of activity.

Chapter 11 Resource Management 183
most appropriate approach for clinicians, therefore, is to
provide cost efficient and effective care for all patients
regardless of payer.
Fortunately, in many circumstances, cost containment
efforts developed to accommodate a given payment
modality can be designed to benefitor at least not
disadvantagepatients of other payers as well. Programs
to reduce length of stay, efforts to improve productivity,
analyses to identify the most cost-effective products, and
benchmarking to identify best practices may be initiated
because of the structure of one payment methodology,
but their beneficial effects need not be limited to patients
of that insurer type. However, because resources are not
unlimited, in different circumstances difficult choices
need to be made. Organizations can rarely respond to
all requests for resources and often are in the position of
needing to select among competing priorities that may
all be necessary and worthwhile. Should the organization
expand the cardiac program or the pediatric program;
replace the ventilators in the critical care units or the
ultrasounds in the echocardiology laboratory; construct
additional ambulatory facilities or additional inpatient
facilities? The decisions will require compromise and
consensus and a clear understanding of the benefits not
only for the organization but also for the staff and, most
important, for the patient. Advanced practice nurses have
the knowledge and expertise to provide the clinical input
and to advocate for the patient. To have a credible voice
in this decision-making process, they must also have a
clear understanding of the business and fiscal issues that
affect resource allocation and management.
increase efficiency for that visit. Reimbursement based
on cases (DRG-based, for example) build in incentives
to reduce the length of stay as well as the resource utilization during the stay. Capitated reimbursement systems
create the additional incentive to reduce the number of
episodes of careadmissions or visits. Individual payer
variations add complexity for providers and consumers.
Some, for example, may offer additional payments for
achieving specific clinical quality outcomes with defined
patient populations such as pediatric asthma patients or
adult-onset diabetic patients. Others may have payment
tiers for certain benefits with different consumer copayments for different levels of services (generic versus brand
pharmaceuticals, for example) (Finkler et al, 2013).
Clinicians, however, generally are not attuned to incorporating reimbursement variables into clinical decision
making for individual patients and prefer to provide care
that is payer-blind. They do have a responsibility, however,
to promote efficiency in the allocation and utilization of
health-care resources, and not only for the viability of the
organization within which they practice. As health-care
costs escalate, insured patients increasingly are at risk
for higher out-of-pocket costs, including deductibles
into the thousands instead of the hundreds of dollars
before the insurer assumes liability, and they are entitled
to value for their expenditure. In addition, social justice
demands that constrained resources be used judiciously
to ensure the maximum availability of health care to all
members of society. In addition, with increased emphasis
and transparency related to cost, patients are now making
choices not only on clinical criteria but also on cost. The

Mediated Roles
Working With and Through Other People
Thomas D. Smith, Maria L. Vezina, Mary E. Samost, and Kelly Reilly
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Explore the relational mechanisms of working with and through others as an advanced practice registered nurse (APRN).
Apply the six APRN core competencies to practice.
Compare and contrast models of APRN collaboration.
Demonstrate APRN leadership roles in interprofessional teams.
Develop a framework to align professional nursing connections.
The four established advanced practice rolescertified
nurse practitioner (CNP), clinical nurse specialist (CNS),
certified nurse-midwife (CNM), and certified registered
nurse anesthetist (CRNA)reflect significant evolution
of the nursing profession and nursing practice over the
past five decades. Progress in role development and advanced practice registered nurse (APRN) integration into
health-care teams has yielded positive outcomes; however,
barriers related to scope of practice (SOP) persist. The
APRN Consensus Model addresses some of the issues of
role definition and SOP for thefour APRN roles (National
Council of State Boards of Nursing [NCSBN], 2008). The
implementation mechanism for the APRN Consensus
Model is Licensure, Accreditation, Certification, and
Education (LACE) (Stanley, 2009). The APRN Consensus
Model/LACE serves the purpose of standardizing APRN
SOP, increasing access, and promoting greater value and
mobility for the APRN within the national health-care

Chapter 12 Mediated Roles 185
setting, will continue to be the hallmark of practice into
the future (p. 8). According to Bleich (2011), APRNs,
as either masters or doctorally prepared clinical scholars,
may not have the extent of formal education in advanced
research methods and statistical techniques, but they are
nonetheless critical to clinical inquiry at the point-of-care and
evidence-driven decision making within the organizational
context. Their clinical expertise and advanced knowledge
of nursing practice can be used in partnership with nurses
prepared with research based doctoral degrees. APRNs
need to engage in a full range of scholarly activities that
include research, evidence-based practice, performance
improvement, teaching and learning, and dissemination
to influence and improve the quality of care provided to
patients, families, and populations (Pape, 2000). Interand intra-professional connectivity will optimize nursings
impact in advancing health via the synergy that bridges
scientific knowledge generation with translationalexpertise
at the point of care. This synergy may also serve to link
nursing better with other health-care professions, giving
nurses a stronger voice in decision-making forums and at
policy tables (Bleich, 2011, pp. 169170).
APRNs function as clinicians using evidence-based
knowledge to provide direct care, diagnose and manage
health-care problems, coordinate services, educate patients and families, advocate for patients, and manage the
health-care system in all its dimensions. This approach to
care supports the continued focus on disease prevention,
health maintenance, and resolution of functional problems
(IOM, 2004). In The Future of Nursing: Leading Change,
Advancing Health, the IOM (2011) stated that nurses
are developing new competencies for the future to help
bridge the gap between coverage and access, to coordinate
increasingly complex care for a wider range of patients,
to fulfill their potential as primary care providers to the
full extent of their education and training, to implement
system-wide changes that take into account the growing
body of evidence linking nursing practice to fundamental
improvements in patient safety and quality of care, and
to capture the full economic value of their contributions
across practice settings (pp. 5354).
system (Rounds, Zych, & Mallary, 2013). It also serves to
support one of the recommendations of the Institute of
Medicines (IOMs) report The Future of Nursing: Leading
Change, Advancing Health (IOM, 2011) to remove SOP
barriers (Stubenrauch, 2010). The Committee for Assessing Progress on Implementing the Recommendations of
the IOM The Future of Nursing report found significant
progress toward reducing SOP restrictions with increases
in full practice status from 8 to 21 states (IOM, 2015).
According to Nursings Social Policy Statement (American
Nurses Association [ANA], 2010), these roles involve
specialization, expansion, advancement, and autonomy,
suggesting the necessary skills of managing people, the
organization, and the environment of care. According to
the IOM (2011), more than a quarter of a million nurses
are APRNs who hold masters or doctoral degrees and pass
national certification exams. APRNs deliver primary, acute
and medical home care as well as other types of health-care
services. For example, they teach and counsel patients to
understand their health problems and what they can do
to get better, they coordinate care and advocate for patients in the complex health-care system, and they refer
patients to physicians and other health-care providers
(p. 52). Specifically, the CNS (APRN) role centers on
the synthesis, integration, transformation, and translation
of best practices as articulated in the literature (National
Association of Clinical Nurse Specialists [NACNS],
2007). Davies and Hughes (1995) note that the term
advanced nursing practice extends beyond roles. It is a
way of thinking and viewing the world based on clinical
knowledge, rather than a composition of roles (p. 157).
This view of the world is an interactive process that emphasizes direct and indirect partnerships with both patients
and a diverse group of health-care providers. In addition
to clinical competency, the varied aspects of advanced
practice also require socialization and interpersonal skills
to form the foundation for collaboration, consultation,
and clinical leadership. Although advanced practice roles
require autonomy and authority to be fully enacted, the
ability to achieve patient and system outcomes is dependent
on partnerships with others to manage interdependent
and interdisciplinary relationships. In fact, the NACNS
(2007) concluded that the synergy of working with,
leading and coordinating teams of professionals in a highly
communicative, focused care environment regardless of

186 Unit 2 The Practice Environment
Accordingly, six core competencies, as shown in
Figure 12.1, further define advanced nursing practice.
These competencies have consistently been identified
as essential features of advanced practice (American Association of Colleges of Nursing, 1996; Davies & Hughes,
1995; NACNS, 2004, 2010; National Council of State
Boards of Nursing, 2006):
1. Coaching: skillful guidance and teaching to advance
the care of patients, families, groups of patients, other
care providers, and the profession of nursing
2. Consultation: patient-, staff-, or system-focused
interaction between professionals in which expertise
is utilized for problem solving
3. Research skills: interpretation, translation, use of evidence, evaluation of clinical practice, and conducting
and active participation in research
4. Clinical and professional leadership: the ability to
manage change and empower others to influence
clinical practice and political processes within and
across the system
5. Collaboration: working with intra- and interdisciplinary
teams toward achieving optimal patient and family goals
6. Ethical decision-making skills: identifying, articulating,
and taking action on ethical concerns at the patient,
family, provider, system, community, and public
policy levels
Given this overview of core competencies, the theme of
relationships within the health-care arena is evident. The
ability to work with and through others is inherent within
these competencies and consequently indicates a strong
foundation for practice. Although not explicitly stated in
definitions of advanced practice, there is an understanding
within interprofessional teams that APRNs must beskillful
and cognizant of the key elements of their partnerships
with patients, families, and other health team members.
Managing the interpersonal strategies of providing care
is critical to success as an independent care provider in a
competitive health-care environment. For example, care
previously provided by APRNs in the complex, acutesetting
is transitioning into the community, thereby increasing the
need for the APRN to assess his or her strengths to provide
accountable practice while working successfully with other
providers. According to the IOM (2004), the opportunities
presented by the current practice environment can be met
Figure 12.1 Core competencies of advanced nursing practice.
Expert guidance Leadership
Research skills

Chapter 12 Mediated Roles 187
unique roles of distinct professions are useful within
the framework of individual competencies, in patient
care the leadership of a team is a supportive experience
for patients, especially for those with limited access to
a health system and those with complex care needs. A
focus on the specific patient and not on professional
turf issues requires skill in leadership and change agency.
In this realm, the blurring of roles is often helpful and
not hurtful.
5. According to Merriam-Websters Collegiate Dictionary
(2003), collaboration means to work together, especially
in a joint intellectual effort. The ANA (2015) Guide
to Nursings Social Policy Statement cites qualities of
collaboration such as a common focus, recognition of
anothers expertise, and a collegial exchange of ideas
and knowledge, and recognizes that nurses uniquely
contribute to wider conversation to address the health
needs of society. Hamric, Spross, and Hanson (2005)
refer to collaboration as a dynamic, interpersonal
process in which two or more individuals make a
commitment to each other to interact authentically
and constructively to solve problems and to learn from
each other in order to accomplish identified goals,
purposes or outcomes (p. 318). By definition, then,
collaboration identifies relationships and involves an
interpersonal process. The focus of the relationship
needs to be positive and grounded in a problem-solving
approach creating interdependence as a mutually
fulfilling experience between the involved parties.
Although collaboration is a cornerstone of many
APRN roles, it eludes some clinicians. Consequently,
models of collaboration have emerged to assist in
structuring relationships and guiding the process of
working partnerships.
6. Ethical decision-making skills are a central component
of effective advanced practice. According to Thompson
and Thompson (1985), To be professional is to be
ethical, and to practice ethically requires an understanding of ethics, values and oneself. The goal of ethical
practice is to do the right thing for the right reason
(Thompson, Kershbaumer, & Krisman-Scott, 2001).
Although grounded in ones values and presentation
of self, the inclusion of the team in ethical decision
making is key to the holistic care of patients. Ethical
clinical practice requires an atmosphere of trust, mutual respect, transparency, and commitment to critical
through a strong foundation of clinical practice, specialty
expertise, and a rigorous graduate education.
With reference to the six core competencies, several
interpersonal themes emerge:
1. Coaching, skilled guidance, and teaching of patients,
families, other care providers, and the profession of
nursing is both a formal and informal role for the
APRN. As mentors, APRNs develop others to either
take the lead or share the pathway of care. As formal
teachers, APRNs assist in the application and evaluation of evidence-based practice in determining and
improving the quality of health-care delivery.
2. Consultation is the direct involvement of another
practitioner, which denotes the need to confirm findings, diagnosis, and plan of care. The responsibility
for care, however, rests with the primary practitioner.
It can require an overlap within the same specialty for
an added opinion or a discussion with a specialist for
another view or preference of treatment. In either situation, the partnership is necessary for optimal patient
care and a deliberate approach in solving problems and
managing care.
3. Research of a practice discipline includes conducting systematic and scholarly inquiry, interpretation,
and use of evidence in clinical practice and quality
improvement. APRN competencies in translating
research into practice, designing innovations based
on new knowledge, or integrating quality evidence
are keys in achieving optimal outcomes (Riley &
Omery, 1996). Innovative change is possible when
health-care professionals come together to redesign
clinical practices. APRNs also contribute in the care
of research participants through supporting accurate,
reliable, and ethical study implementation. Additionally APRNs need to participate and contribute in
creating policies and procedures and care standards
for implementing clinical research across the continuum of health-care settings (National Institutes of
Health [NIH], 2010).
4. Clinical, professional, and system leadership can be powerful when approached in an interdisciplinary manner.
Leadership competencies of APRNs are required for
assessing and influencing nursing practice and patient
outcomes in populations, health-caresystems, regulatory
requirements, and health-care finance. Although the

188 Unit 2 The Practice Environment
Mutual respect for the expertise of all members of the
team is a linchpin to successful collaboration. This
respect is communicated to the patient.
Communication that is not hierarchical but rather two way
ensures thesharing of patient information and knowledge.
Two-way communication between equals serves as a
framework for difficult conversations. Questioning of the
approach to care ofeither partner cannot be delivered in
a manner that is construed as criticism, but as a method
to enhance knowledge and improve patient care.
Cooperation and coordination promote the use of the
skills of all team members, prevent duplication ofeffort,
enhance the productivity of practice, and improve the
patients experience of care.
Optimism promotes successful teamwork when the
involved parties believe that collaboration is the more
effective means of promoting high-quality care.
Although these attributes are key in any collaborative
relationship, it is primarily the unique contribution of
each member of the team that determines a successful
Although there are several models of collaborative
practice, they often are distinguished by the response to
two questions:
1. How is the expertise of each team member used to
the fullest?
2. Who is responsiblefor decision making and patient care?
Table 12.1 summarizes three practice models commonly
used in primary care (Strumpf & Whitney, 1994) and one
thinking and reasoning. To create this atmosphere,
APNs, as the managers of care, need to work with
others in an inclusive manner, so as to build a team
whereby the ability to express values, feelings, beliefs,
and knowledge can be encouraged and ensured as the
ethical dimension of practice emerges.
The basis of collaboration is the belief that high-quality
patient care is achieved by including the contributions of
all care providers. In The Future of Nursing: Leading Change,
Advancing Health, the IOM (2011) stated that being a
full partner transcends all levels of the nursing profession
and requires leadership skills and competencies that must
be applied within the profession and in collaboration with
other health professionals (p. 35). The Macy Foundation
(2010) states that mounting research shows that health
care delivered by nurses, doctors, and other health-care
professionals working in teams not only improves quality, but also leads to better patient outcomes, greater
patient satisfaction, improved efficiency and increased
job satisfaction on the part of health professionals (p. 2).
Collaboration is often cited as the key to success for any
initiative that extends beyond an individuals scope of activity. Collaboration is therefore the foundation ofeffective
patient care. According to Arcongelo, Fitzgerald, Carroll,
and Plumb (1996), a variety of interpersonal attributes
are necessary for successful collaboration. These include
trust, knowledge, shared responsibility, mutual respect,
positive communication, cooperation, coordination, and
optimism (p. 107). See Figure 12.2. The authors define
these attributes as follows:
Trust among all partiesestablishes a high-quality working
relationship; it develops over time as the parties become
more acquainted and establish norms. According to
Hamric, Hanson, Tracy, and OGrady (2014) trust
also depends on clinical competence (p. 306).
Knowledge is a necessary component for the development of trust. Knowledge and trust remove the need
for supervision.
Shared responsibility suggests joint decision making for
quality patient care and outcomes, as well as accountable
practice, within the organization.
Figure 12.2 Collaboration attributes.
Collaboration Is the Key to Success
Shared responsibilities
Mutual respect

Chapter 12 Mediated Roles 189
Regardless of the model of collaborative practice, the
elements of trust and a positive working relationship are
vital. Collaborative relationships are a work in progress,
not facilitated by inflexible expectations or boundaries.
Over time, mutual expressions of expertise become
grounded in an invisible pattern that is the glue of the
successful relationship, reflective of growing skill, trust,
and confidence among partners.
The advantages of collaboration often begin with negotiation by the involved professionals regarding which
patients and conditions are best managed by the APRN
or the physician. This process may seem to be a hurdle to
competent and successful APRNs, but armed with data,
performance indicators (both financial and clinical), and
the maturation of ones practice, the process of collaborative
decision making promoteseffectiveness of care. Forexample,
in the management of chronic illness, APRNs tend to prescribe fewer drugs, order fewer tests, choose less expensive
treatments, and spend moretime with patients (Fitzgerald,
Jones, Lazar, McHugh, & Wang, 1995). According to hospital
salary surveys, the cost of an APRN is often 50% of the
physicians or less. Subsequently, an effective collaborative
APRN/physician practice would enable physicians to spend
more time with patients with more complex health needs
while APRNs focus on the care of more stable patients, as
well as helping patients traversethe health-care continuum
in managing their complex diseases.
In all health-care settings, it is becoming an increasing
challenge to provide the ongoing surveillance and case
management that can support sick and frail patients to
function at their highest level possible. In a study of elders,
Naylor and colleagues (1994) found that acute-care nurse
collaborative model being adopted in various health-care
settings (Arcongelo et al, 1996; Matthews & Brown, 2013):
1. The parallel model
2. The sequential model
3. The shared model
4. The collaborative model
In the parallel model, the APRN manages stable patients
and the physician cares for those who are more medically
complex. In thesequential model, the APRN performs the
intake assessment and the physician assumes responsibility
for differential diagnosis and management, or the pattern
may bereversed with the physician screening all patients and
delegating the care of patients identified as less complex to
the APRN. In theshared model, the APRN and the physician
carefor an individual patient on an alternating schedule and
based on patient needs. Arcongelo and colleagues (1996)
identify a fourth model, the collaborative model, which
involves the APRN as the primary care provider without
regard for the complexity of the problem. The APRN and
physician collaborate based on an egalitarian partnership
to deliver high quality disease management using APRN
full abilities: a unique professional lens,expertisein teambased care and patient partnerships (Matthews & Brown,
2013). The communication in this model is ongoing, may
transition to a comanagement arrangement during an
unstable or complex period, but always involves theinput
of the two professionals in establishing the plan of care.
One outcome of this style is the ability for the APRN to
expand his or her knowledge and skills within the complex
realm of patient care and establish closer contacts with
consulting team members while managing the complexity.
Table 12.1
Models of Collaborative Practice
Parallel Model Sequential Model Shared Model Collaborative Model
APN role in patient
Manage stable patients Perform intake
Manage patients identified
by the physician to be
less complex
Manage all levels of
Physician role in
patient care
Manage medically
complex patients
Diagnosing and
management of
Initial screening of
Manage more complex
Comanage during
unstable periods
Collaboration between
APN and physician in
plan of care

190 Unit 2 The Practice Environment
effective manner. Embedded in these partnerships are
the issues of relationships within the health-care team,
communication styles, trust, and the ability to interact
within these clinical relationships without a hierarchical
framework. Although many APRNs have formal consultative relationships within their SOP, others do not. In
addition, these formal structures vary among states and
health-care institutions with a range of directives from
state boards, often from different disciplines. National
efforts are underway to remove SOP barriers and allow
for increased reimbursement for APRN services but they
have not yet been implemented (IOM, 2015). Accordingly,
these changes can result in significant savings and increased
access, as well as performanceimprovement in patient safety
and quality of care. With legislation and statute aside, the
ability to work within a model of consultation and referral
is necessary. Each member of the health-care team has
knowledge and skills to offer the other and a partnership
can often effect changes in practice and influence patient
care outcomes that would not be possible if managed
alone. Many consultative practices are also influenced
by the environment whereby specialty and primary care
is clearly differentiated. In these situations, consultative
relationships are vital to improved care processes.
Often consultation and referral activities are confused
with supervision, comanagement (the working together
to manage a complex case), and direct oversight. In these
situations, the accountability for practice may become lost
and roles are blurred. The limits of ones practice expertise
or the need to receive advice should be viewed as complementary, not as a deficiency or take over approach.
The professional interactions inherent in consultation
and referral expand the APRNs ability to work with and
through others while maintaining autonomy over the
situation until there is a mutually identified decision that
a change in care is necessary. Although comanagement
and referral (the relinquishing of care temporarily or
permanently) may have different themes, the goal of care
is still accomplished within a partnership mode. Hamric,
Spross, and Hanson (2005) state that APRNs themselves
are often confused about the differences. They refer to a
more thoughtful definition of collaboration described as
a dynamic, interpersonal process in which two or more
individuals make a commitment to each other to interact
authentically and constructively to solve problems and to
learn from each other in order to accomplish identified
practitioners (ACNPs) were able to reduce posthospital
complications and readmissions. The management of acute
illness of established patients has also shown a decrease
in complications and cost while maximizing the quality
of life for patients. Physicians are then available to deal
with those situations that require the clinical decision
making and intervention of specialized medical care. It
is becoming increasingly apparent that future trends in
health-care reform and public reporting will require greater
collaboration and role recognition among all health-care
providers as a strategy to relate effectively and efficiently
with all patients.
Although barriers to collaboration persist, progress has
been noted in interprofessional practice. Advanced practice
nurses (APNs) areleading interdisciplinary teams, improving
primary care access, managing care of vulnerable populations,
and improving patient and population outcomes (IOM,
2015). Barriers to collaboration have been rooted in the
many traditions of the Doctor-Nurse Game, which range
from sex-role stereotypes to incongruent expectations of
knowledge and skill acquisition. Intertwined within these
concepts are those related to cultural, social, psychological, and financial complexities of the health-care system.
Nonetheless, when patient-focused approaches to health
care are endorsed and when interprofessional education
and team-based collaborative practice models are adopted,
the critical aspects of collaborative relationships, skills,
and practices are uncovered. The opportunities in which
patient-focused approaches fully engage among various
health-care disciplines become self-evident over time. In
other words, the dimensions of the physician-nurse relationship are fundamentally tied to the quality of patient
care (Brandt, 2001). This observation alone provides the
health-care system and clinicians with primary motivation
to encourage effective relationships between professionals
to identify opportunities for working through and with
one other.
The nature of advanced practice is such that most
patient care can be managed because of the skill and
knowledge of the practitioner within the role. However,
each practitioner acknowledges the critical significance
of consultation and referral when used in a timely and

Chapter 12 Mediated Roles 191
to meet the needs of patients, families, communities, and
populations to provide the care they want and control
costs in health care.
Interdisciplinary teaming, currently referenced as interprofessional collaboration, was proposed decades ago as an
alternative model of care (Pfeiffer, 1998). Interdisciplinary
teaming requires that the members of the health-care
team integrate their disciplines work and create plans of
care together, centering this plan on the patients needs.
This form of teamwork, interdisciplinary care, has been
defined as a special form of interactional interdependence
between health-care providers who merge different but
complementary skills in the service of patients and in
the solution of their health problems (Tsukuda, 1990,
p. 670). See Figure 12.4.
goals, purposes, or outcomes. The individuals recognize
and articulate the shared values that make this commitment
possible (p. 318). Within this framework of collaboration, the varying processes of consultation, referral, or
comanagement may assume the added dimension of a
therapeutic, professional relationship acknowledging the
role each member plays while supporting the complexities inherent in the delivery of high-quality patient care.
Although knowledge, skill, and clinical expertise are all
key factors in day-to-day practice, the elements of working
with each other in this collaborative manner will determine
and distinguish the best practices.
The need for integrated health-care teams is fueled by
several factors, including patient safety; the increasing
complexity of patient needs, especially among the growing
population of elders; expansion in the continuum of care
in various health-care delivery models; the sophistication
of telecommunications and information networks; and
changes in methods of health-care financing and reimbursement regulations. It is also evident that members
of the interprofessional health-care teamphysicians,
APRNs, registered nurses (RNs), social workers, and other
cliniciansoften practice independently of one another,
rendering care as if services for thesame patient or groups of
patients were unrelated. This can create an uncoordinated,
conflict-laden environment resulting in a diminished voice
for patients and families to participate in their own care.
Ineffective teamwork and communication are primary
root causes in medical errors becoming the third leading
cause of death in the United States. Estimates of healthcare costs for medical errors are more than $17.1 billion
a year with an conservative total monetary loss of up to
$73.5 billion a year based on the cost of quality-adjusted
life year (QALYan economic evaluation to assess the
value of money for medical interventions) (Andel, Davidow,
Hollander, & Moreno, 2012; National Patient Safety
Foundation [NPSF], 2015). Interprofessional teaming
differs from the multidisciplinary approach to care, which
has been compared with the parallel play of children with
limited interactive and intersecting activity (Clark, 1994).
See Figure 12.3. According to Cronenwett and Dzau
(2010), interprofessional training and teaming are critical
Figure 12.3 Multidisciplinary approach
to patient care.
Other clinicians
Physician APN
Figure 12.4 Interprofessional approach
to patient care.
Other clinicians
Physician APN

192 Unit 2 The Practice Environment
3. Knowledge
Roles, responsibilities, and SOP for each discipline
Role of the extended team
Group dynamics
Application of clinical concepts and quality measures
among disciplines
Up-to-date knowledge of the health-care environment, policy, and technology
Inherent within this interdisciplinary framework,
collaboration underpins the field of day-to-day practice
within a team concept. According to Tsukuda and
Stahelski (1990), collaboration takes on the dimension
of cooperation with others, adding trust as an essential
component of this interactional style because patient
outcomes are consistently dependent on the efforts of
others. As a team member, one may ask the following
Are my own goals consistent with team goals?
Do I advocate solutions for problems that will benefit
team members?
Do I work for consensus and focus on performance
and measureable outcomes?
Do I cooperate with other team members activities?
Do I do an equitable share of the group workload?
Do I feel individual responsibility for the joint outcomes
of the group members?
Do I support the team in dealing with larger organizational and regulatory issues?
Do I view my contributions as belonging to the group
to be used or notas the group decides?
Do I listen to team members in a positive and respectful
Do I actively participatein team meetings and assignments?
Advocates of interdisciplinary team approaches to care
realize that there are many psychosocial influences on
health and disease. This underscores the importance of
relationship-centered care (Tresolini & The Pew-Fetzer
Task Force, 1994) and patient-centered care (Coles,
1995), which are based on interpersonal communication
techniques and a collaborative care model. A paradigm
shift for all members of the health-care team may be necessary because new core competencies are required and
need to be role modeled for the successful transition to
The term complementary defines the team approach.
However, a collection of like-minded individuals does not
automatically result in an interdisciplinary team. Because
of the nature of this teaming, there must be a clearly defined purpose, goal, and approach to team activity, shared
phraseology to ensure effective communication (e.g., SBAR
communication), as well as the value and understanding
that mutual accountability of each team member is crucial
to the teams overall performance. The primary purpose
of this type of team is collaborative decision making for
and with patients. Decision making in this model occurs
in a unified timeline. Often, in a multidisciplinary team
approach, a sequential timeline is experienced as a dependent process in which the final decision is made by the
lead member who pulls everything together. This type
of decision making is limited, and potentially ineffective,
when complementary activity is desired.
For the APRN, the influence of interdisciplinary teams
is powerful when practitioners practice at thefull SOP with
clear roles and responsibilities and shared values. Creative
teamwork can be achieved when the entire team caring
for patients can actively participate in planning, decision
making, problem solving, and include patients and families
in their care. Changing the norms of practice, however,
may be necessary. Interdisciplinary teams are the epitome
of working with and through others while recognizing the
importance of an individuals clinical expertise.
There are several dimensions to consider when implementing interdisciplinary team relationships. According
to Howe, Cassel, and Vezina (1998), these dimensions
include the following:
1. Skills
Conflict resolution
Team interaction
Outcomes-focused care
Performance improvement
2. Attitudes
Respect for other disciplines
Respect for patient and family input
Respect for patient management and patient-focused
Awareness of outcomes-based practice

Chapter 12 Mediated Roles 193
nursing education lay the foundation for the advanced
practice platform. Common ground skills and competencies include patient assessment, health promotion
and maintenance, health education, advocacy, caring,
accountability, continuity, and collaboration with other
health team members. This overlap and sharing of skills
create a bond of practice between RNs and APRNs
forming professional nursing connections. How do these
two groups move together in partnership? Hopefully,
they join together with respect for the value of each role,
intending to effectively use the expertise of each professional while avoiding duplication of effort and promoting
true collaborative relationships. Such connections can
broaden the scope of health care and achieve professional
satisfaction for both RNs and APRNs.
Regardless of the common ground, however, each
advanced practice specialty has dealt with resistance from
other nurses because advanced roles have often represented
innovations in practice that shook the status quo of the
nursing establishment and the overall health-care system
(Bigbee & Amidi-Nouri, 2000). Rigid boundaries were
often created and the struggle for recognition and acceptance followed. However, through organized and focused
educational and political efforts, tensions were lessened
and improved relationships flourished.
The roles of the RN and the APRN sometimes clash
within the context of leadership for the delivery of
patient care. Once an understanding of expertise and
specialization is clearly reached and communicated, the
contribution of each role can be qualified and recognized
and a complementary approach to health care defined.
Evaluative research can also assist in this recognition and
educational processproviding data to illustrate the effect of advanced practice nursing care on quality patient
outcomes. Together, professional connections between
the RN and APRN can be fortified and not diluted by
professional conflict.
The common ground between RNs and APRNs creates
a powerful force in health-care delivery. The professional
bonding that exists between both groups reinforces the
image of the RN and the APRN as coleaders of care.
By practicing together, the RNAPRN team can design
approaches to care that recognize each others respective
strengths and expertiseresulting in a dynamic practice
arena free of hierarchy.
occur. APRNs are often members of these teams and are
positioned to initiate the transition to a more collaborative
and patient-focused approach in their practice. APRNs
often assume a mediator role to introduce these changes
in the delivery of patient care and to assist the team in
its growth and development in the core competencies of
interdisciplinary team approaches.
APRNs may take a leadership role in influencing
stages of team development. Their role is easily linked
to the various members of the health-care team, allowing
APRNs the advantage of connecting with each discipline,
clearly expressing the similarities and the differences of
each members role and contribution. With this common
ground set, the formation and development of a team
can occur.
According to Tuckman (1965), four stages of team
development are discussed:
As implied by the stages, the creation and maintenance
of teams is personnel intensive with professional adjustments required by every member of the team. Successful
outcomes also imply that at least four conditions are
met: The task is suitable for teamwork, the team must
include the right clinical skills to perform the task, team
members must combine their resources effectively, and
the organization must provide a supportive context for
the team (Dow et al, 2013).
Roles and relationships will be challenged, but the
team will also move to a new level whereby extraordinary
achievements and improved patient care can occur. In
this context, interprofessional teaming with its strong
emphasis on relationship-centered care is a requisite skill
for the 21st century.
Expanded roles for nurses span a century of growth and
development, with the earliest days of clinical specialization
in anesthesia, operating room, and obstetrical nursing.
However, the knowledge and skills required in a basic

194 Unit 2 The Practice Environment
group with the intent of assessing roles, expectations, and
influences on practice.
1. How would you describe your role?
2. How would you describe your working relationship
with physicians, other nurses, and other members of
the health-care team?
3. What does referral mean to you?
4. What does consultation mean to you?
5. How open are members of other disciplines in taking
direct referrals or consultation from you?
6. What degree of authority do you experience in these
situations and in your role?
7. Do you observe that you bring about change and a
higher order of knowledge to your practice area?
8. Can you discuss a situation that may exemplify your role,
especially regarding your work through other people?
The enactment of the advanced practice roles of the
APRN, the CNS, the CNM, and the CRNA are best
detailed through the narratives set forth by the following
exemplars. Using the standard set of interview questions listed in the text that follows, these enactments
are related to existing practice settings. See Boxes 12.1
through 12.6.
Advanced Practice Nurse
Interview Questions
To guidetheinterview process for chosen groups of APRNs,
the following questions were used consistently for each
Box 12.1
The Acute-Care Nurse Practitioner
This group of acute-care nurse practitioners (ACNPs),
situated within an oncology inpatient practice, describes their role as geared to management of their
patients experience of illness. The patients diagnostic
workup is often completed before admission in the
ambulatory setting. Therefore, the patients in-hospital
experience focuses on the management of the acute
phase of illness and treatment options as the goals of
care. They describe their perspective as multidimensional. Using their RN background, they always view
the patient in a holistic manner. Advanced practice
clinical competencies engage their ability to case
manage and guide patients and families through the
complexity of health care. Within this framework,
the ACNPs relationships with the health-care team
are key because they spend significant amounts of
time discussing medical management and locating
resources, managing symptoms, integrating feedback
from other disciplines, and identifying alternatives
to the health-care system when challenged by the
limitations of third-party payers. Given their range
of activities, this group of ACNPs consistently relate
to a variety of other disciplines, primarily medicine,
nursing, and social work.
This group describes their autonomy as follows:
We feel that our common ground is the care of
the patient. Working collaboratively with the interprofessional team in the lead position, we decide
the day-to-day care for our patients, and in acute or
critical episodes, we often independently manage the
process. Although critical incidents may be a time when
the physician takes a more active role, this does not
necessarily translate into the need to take over. The
goal is to work togethernot to work around each
other or without each other. The ACNP is usually
the leader of care because of several factors, including the close relationship to the patient and family
members, the advantages of consistency of care by
the ACNP, and well-defined collaboration between
physician and ACNP.
Regarding their relationships with RNs, the ACNPs
state: There is nothing better than working with

Chapter 12 Mediated Roles 195
a competent nurse. When this relationship occurs,
there is such a strong bond that you firmly believe
that there is absolutely nothing that can stand in the
way of quality. On the other hand, ACNPs state
that some nurses can become more passive about
patient care when relating to an ACNP. Because the
RN recognizes the nurse in the ACNP role, the
RN may relinquish aspects of his or her responsibility for patient management or assessment to the
ACNP. This transfer rarely occurs within the RN
physician relationship. NPs must therefore carefully
assess the nature of the ACNPRN relationship to
avoid jeopardizing their ability to work through
others while facilitating the advanced practice
Within the ACNP role, referrals are commonplace
ACNP to nutritionist, social worker, pharmacist,
physical therapist, and home care services. Physicians
often refer their patients to ACNPs, acknowledging
their specialization, expertise, and consistency of
care. Consultations are more informal within the
inpatient setting. When acute patient situations occur,
however, clinical consultation is common. ACNPs
state: Not a day goes by that I am not involved in a
clinical consultation primarily focused on symptom
management, such as pain control, the side effects
of chemotherapy, nausea, vomiting, constipation,
or palliative care. This type of consultation is almost always verbal for, it seems, physicians want
to maintain control of the written consultation
process within the hospital experience. ACNPs
consult other ACNPs as well, often involving clinical
specialization expertiseusually within a verbal,
face-to-face framework.
The degree of authority within the discipline
of nursing is explained by acute care ACNPs in a
variety of ways. ACNPs are integral in the decision
making about their patients and have significant
influence on the nursing care being delivered. Using
a specialization approach, ACNPs take advantage of
opportunities to teach about clinical sequelae and
implications. One ACNP states: I often teach at the
bedside about what is going on with the patient, and
I am watchful for the types of questions the nurses
have. This helps me observe the growth of the staff
and assess their advancing competency. It is really a
very rewarding experience for me. Through rounding
with staff nurses, ACNPs also have the opportunity
to clarify the patient story and often act as a facilitator of communication about patients among team
members. ACNPs state their role as performing the
editing roledistinguishing the critical elements
of the patient story and routing the necessary data
in a more concise and relevant way to obtain what
is necessary for their patients. As one ACNP stated,
Our role within the interdisciplinary team is one
of monitor of the communication patterns and the
perspective at hand. We often translate what is going
on into a relevant, concise language that evokes a
rapid, clear understanding by those team members
who need to hear the information.
According to this group, the design of the ACNP
embraces many relationships within the health-care
team and consists of these major components:
1. Gatekeeper
2. Decoder of the complexity of the situation
3. Director of care, delineating roles and responses
4. Problem solver, often suggesting alternatives when
barriers arise
5. Provider of a secure environment for staff nurses to
ask questions and learn
6. Guide for directing the patient care experience,
providing the driving force behind what needs to
be done, when, and why
Integral to these components is the ability to work
with others, to recognize the many roles inherent
within the health-care team, to value the teams input
and contribution, and to recognize that influencing
others should be always focused on the unified goal
of high-quality patient care.

196 Unit 2 The Practice Environment
TheCNSs describetheirrole as multifunctional, defining
their framework of practice as more focused within a
nursing modelratherthan medicine.CNSs categorizetheir
roleinto two primary domains: clinical and professional.
Clinically, thisCNS group describestheirrole asincluding
a major teaching component and direct clinical practice
to facilitate and influence care of complex patients.These
functions are often intertwined because they routinely
bring about change and a higher order of knowledge
by role modeling, mentoring, and coaching staff to perform at the next level. CNSs also intervene within the
health-care team to make clinical recommendations to
changethe course of action orresolve conflictsfor optimal
patient care. Professionally, the CNS also assumes major
responsibilitiesforthe development of policies, procedures,
protocols, and standards of care.Within this context, the
education of patientsin health promotion andmaintenance
is key. Standards of care are holistic in nature, spanning
the physical, psychosocial, and spiritual needs of patients.
The needs of nurses are also critical.TheCNS encourages
the professional growth of staff, often provides career
counseling, and directs the building of expertise among
nurses in a specific, individualized manner.
TheCNSs describetheirrolewith physicians as collegial
with a defined focus on specialty patient care management,
often receiving referrals for a specific patient population
(e.g., diabetes) or an occurrencesuch as death or dying and
bereavement.CNSs are consistent in their viewof the big
picture, focusing not just on disease and pathophysiology
but on the patients response to the disease. With other
nurses, CNSs describe their role as an enablerone of
camaraderie focused on patient care. CNSs also provide
clinical, professional, and legal clarification regarding issues
of care to ensure a safe patient environment.
When asked about autonomy, this CNS group cited
self-direction and motivation as key elements in working
with others. Several strategies are used to engage others
in change and ultimately provide state-of-the-art, valid,
and effective approaches to care:
1. Use benchmark data and national standards to
energize staff to change or modify practices.
2. Develop and educate staff so they can question their
patient care environment and relate to a higher level
of performance through evidence-based practice
and scholarly query.
3. Involve staff in various levels of patient care projects,
moving forward together in change.
4. Ground all projects in theliterature and best practices
so as to base decisions on evidence and promote
confidence in the process.
The CNS role engages an inclusive approach within
these strategies that guarantees a successful and lasting
outcome over time.
Referrals are routine in complex cases. The CNS
is often the originator of referrals to other members
of the health-care team but integral to bringing team
members together to problem solve. Inclusiveness is
again a key element of the CNSs practice domain and
a hallmark of their effectiveness in patient care through
their ability to relate to others.
Consultation, on the other hand, is associated
with the level of the CNSs clinical expertise and is
often initiated by other members of the health-care
teamphysicians, nurses, and social workers. As an
inductive thinker, the CNS has a clearly articulated
interest in the patient experience of care. Using these
tenets of practice and changestandards, safety, and
ethicsthe CNS is able to define a plan for care,
engaging caregivers to undertake the plan and empowering others to assume an appropriate trajectory
for the patient.
As the integrator of care, the CNS exemplifies how
positive interdisciplinary relationships ensure positive
outcomes for patients. CNSs are teachers, clinical
experts, care providers, case finders, role models, mentors, patient advocates, coaches, team members, policy
makers, project leaders, innovators, case managers, career
counselors, and change agents. With a vision of best
practices as their foundation for care, the CNSs hold the
value of expertise and dynamic working relationships
within the health-care team as critical elements to the
success of their role.
Box 12.2
The Clinical Nurse Specialist

Chapter 12 Mediated Roles 197
Midwives in a combined ambulatory and inpatient
setting describe their advanced practice role as primary caregiver of women along the life cycle with a
focus on low-risk obstetrical and gynecological care,
health promotion, wellness, family-centered care, risk
assessment, and management of common illnesses and
acute conditions. Clinically, this group views their role
as centered on direct care with a strong emphasis on
patient education and health promotion. Their relationships with other members of the health-care team
revolve around this focus. Midwives independently
care for a patient caseload, often comanaging more
acute conditions with physicians or employing the
physician as consultant.
Regarding referral, midwives in this practice
describe the process as formalized and often interchangeable with consultation. They define many of
their referrals as transfers to the care of a physician
because of a specialized need of the patient over
time. Ongoing referrals to other disciplines are also
common, usually engaging the services of social
work and home care. In these instances, the midwife maintains the primary care responsibility for
the patient. With consultation, the process is also
formal. Using written communication, consultations
are often provided through the required practice
protocols that identify the consulting physician and
the decision guidelines for the consultation. Within
this collaborative relationship, the midwife is able to
transition the care of the patient when a condition
warrants. This can be accomplished in a comanaged
arrangement or by a referral of the care responsibility
to another caregiver. However, the midwife has an
expectation to be involved in the communication of
the plan of care and the ultimate follow-up of the
patient being referred. The midwife explains that
the relationships with physicians in my practice are
necessary and denote many shared responsibilities. I
find this relationship to be within an interdependent
framework because we both need to work together to
manage the patient safely in given situations. I have
a consulting agreement with a primary physician for
immediate feedback and intervention as well as with
other physicians who are colleagues and can be employed for a less acute need. But I also have the need
to maintain my primary care role for my patients.
Working with the nursing staff involves interdependence. The need for the RN to facilitate a plan of
care and become integral in the assessment and the
education of patients is key. One midwife states, I
find that once my role is accepted and understood,
positive relationships follow and communication
about patients is facilitated. I admit that I need
nurses to ultimately deliver good patient care. I
cannot do everything myself. Nurses and other
health team members who seek out the midwife as
primary caregiver ultimately improve the patient
experience because the model of working together
and understanding the role is achieved. One midwife
states that over the past decade this recognition of the
midwife role has improved tremendously, especially
because of updated SOP legislation and changes in
third-party reimbursement.
When asked about autonomy and authority
over practice, midwives strongly identify that their
influence over care processes is recognized by others.
The primary reason for this influence is the public
respect, acceptance, and demand for their roles and
services. They add that this authority is stronger and
more flexible in an ambulatory setting and can be
less autonomous in a hospital-based birthing unit,
especially when associated with a medical residency
program. Interdisciplinary competition in these settings can affect the perceived authority and working
relationships of the midwife with other clinicians, as
well as patients.
When discussing their relationships with nurses,
midwives were clear that within the specialty of womens health RNs do not abdicate components of their
roles to midwives. RNs often question an approach to
care, exchange ideas to complement care, and practice
as team members. The specialty of womens health is
Box 12.3
The Midwife

198 Unit 2 The Practice Environment
often not characterized as illness-focused but within a
health promotion or health maintenance framework,
enabling the team approach to flourish. Respect for the
teams contribution to the varied aspects of the needs
of patients enables the nurse-midwives to work effectively with and through others. As one nurse-midwife
summarized her role: Being on the same page in our
plans for care is easily delineated within this advanced
practice role. Thus collaboration is a natural outcome.
Respect is key, and once earned, paves the way to
collaborative practice.
Box 12.3
The Midwife (Continued)
This group of primary care NPs view their role as provider of a comprehensive holistic health-careexperience
for their patients. With independence and autonomy,
the primary care NP has a threefold responsibility to
assess, diagnose, and manage a variety of common
and chronic illnesses within all the dimensions of the
physical, psychosocial, and financial elements of care.
My caseload of patients is a common reference point,
delineating the accountability of this group of NPs
for their patients over timenot limited to a hospital
experience but to the continuum of care. In primary
care, the NP possesses a leadership role in the practice
generally by providing a surveillancefunctiona third
eyealways watchful of theeffectiveness of day-to-day
patient care delivery. The need to evaluate systems and
clinical outcomes is essential to the role.
The team approach in this type of practice is fundamental and involves a strong interdisciplinary, participative approach to care. Patients areindependently
managed, comanaged with physicians, or referred within
their continuum of care. The need to relate effectively
with all members of the health-care team is constant.
Multidisciplinary options coexist within an interdisciplinary frameworkcreating many opportunities for
therapeutic relationships among staff, patients, and
family members.
Within the primary care practice, RNs are the heart
of any clinical operation. The RN complements the
APN role, especially in the areas of patient teaching,
patient monitoring, and data gathering. Although roles
are often strongly delineated, sharing clinical activity
among health-care team members is consistent and
Because of the primary carefocus, referrals to specialists are commonplace. However, as one NP explained,
Losing the primary relationship with a patient to a
specialist is a concern. The information and insight
thespecialist provides willenhancethe carethe patient
receives from his or her primary care provider. There are
also instances when a specialist and primary care provider
work collaboratively on the health-care management of
a patient over the longer term. Feedback on the means
to best manage the patient is the expected outcome.
One NP stated: Weexpect to have our patients return
to us for their care and to benefit from the expertise
and evaluation by the specialist.
Consultations, on the other hand, are frequently
engaged in by other caregivers. Within a mature primary
care practice, a multidisciplinary team approach is often
developed. Formal consultations usually occur within
the practice. The opportunity to have curbside or
hallway consultations with these same specialists or
experts exists as well. This type of consultation is often
informal. The NPs from this practice cited that the key
criteria for successful and effective consultations of any
type include the development of positive relationships,
a clear direction of the plan of care, and a model of
inclusivity among team members.
Box 12.4
The Primary Care Nurse Practitioner

Chapter 12 Mediated Roles 199
Primary care NPs describe their authority as an
essential part of their potential for success in their role
while maintaining autonomy and a knowledge base
to provide sufficient holistic primary care to patients.
Practicing side-by-side with physicians and other NPs
creates opportunities for sharing advice or consultation.
Leading patient care in this practice setting is very
satisfying and empowering to this group of APNs. At
the same time, however, this sense of control and satisfaction occurs only when interdisciplinary teamwork
is achieved by doing the following:
1. Listening to others
2. Teaching others
3. Demonstrating the APN rolein positive, creative ways
4. Communicating openly
5. Demonstrating expertise
Respect from other members of theteam enables the
primary care NP to facilitate and lead care effectively.
When sharing the same mission within this framework
of practice, advancement of learning and change occurs.
By empowering and educating staff at all levels, the
barrier of the task is removed and has been replaced
with a connection to the patients illness experience.
Assisting staff to understand the rationale for care is a
definitive way to initiate change and a higher level of
performance. In addition, the primary care NP often
exhibits his or her own clinical specialization and
expertise, which may provide a different perspective
of care, adding to the knowledge base of the staff. As
educator, the NP is capable of working through other
people, engaging the staffs interest in the mission and
work at hand. Knowledge is power, and this power
translates into effective practice.
This group of NPsworks in isolated or underserved areas
with patientswho havelimited access to health care. Some
rural health NPs are the primary caregiver to an entire
community. Rural patients have higher rates of chronic
disease and have a higher utilization ratefor Medicare and
Medicaid compared with more populated areas. Access
to specialty providers is more difficult as well, with the
average patient driving between 20 and 60 miles to see a
specialist; therefore,rural health NPs provide moreextensive
care compared with their primary care NP counterparts
in large practices with easier access to specialists.
The role of rural health NPs is to diagnose and treat
health disorders, promote health and prevent disease, and
provide health education and counselling. They describe
their practice as highly autonomous, relationship-based,
and extremely rewarding. Interprofessional collaboration poses challenges because of distance, outdated
technology, and communication barriers. Quality of
care is improved when the rural health NPs take on
the leadership and management roles in patient care,
support communication and follow ups through the
use of technology, and understand the rural cultures.
Rural health NPs cite the following requisite competencies for their specialty practice:
1. Home-based primary care to reduce the travel
burden, increase the compliance of health regimens,
and improve health outcomes for patients
2. Aligning patient care teams through relationships
and technology
3. Telemedicine consults and digital communication
to improve access to high-quality care that includes,
but is not limited to:
a. Acute care
b. Radiology
c. Pharmacy
d. Psychiatric services
e. Lifestyle coaching
4. Support for caregivers to increase coping and
decrease stress
Box 12.5
Rural Health Nurse Practitioner

200 Unit 2 The Practice Environment
5. Problem solving and innovations to generate solutions and overcome challenges with creativity and
6. Interprofessional learning and education
The ability of therural health NP to manage complex
cases in the home encourages patients to be partners
in identifying health-care issues, discussing possible
solutions, and developing and implementing plans of
action together. I get to the point where I look forward
to Joan calling me on Wednesday afternoons. You know
three oclock comes and I know I have to be near the
phone and be ready for her call, and then I give her
all my numbers. Shell check with me to see if I have
any pain, how the week went and so forth, which I
find is good, explained rural veteran Oscar Bourbeau
(retrieved from
Rural health NPs agreethat discussing risk factors (i.e.,
smoking and nutrition, focusing on exercise, medication
adherence, and stress management) encourages health
promotion and involves community-based organizations
in the care of patients. When patients are hospitalized,
we need to make connections, understand the goals of
care, make visits when they are discharged home, and
implement an ongoing strategy for return to optimal
health. Therural health NP must develop and practice
at his or her full SOP to improve the health of rural
populations. SOP barriers and outdated technology
that were once a hindrance in providing high-quality
care are now becoming opportunities and strengths
within this growing profession. Rural health NPs have
successfully lobbied in the years leading up to the
Affordable Care Act and in the years after to increase
access to quality rural health-careservices and to remove
barriers to NP SOP in many states to ensurethere are a
sufficient number of providers to take care of the rural
and underserved populations of this country. There
is a great deal of satisfaction in the role, from building
strong interprofessional and interpersonal relationships
with all members of the health-careteam, including the
patient and their family, providing innovative and high
quality care to individuals, families, communities, and
populations, and having a lower cost of living with higher
pay [compared with primary care NPs in large urban
practices] that all makefor a very rewarding profession.
Box 12.5
Rural Health Nurse Practitioner (Continued)
The role of the CRNA within a hospital practice is
described as an advanced practice specialty with a
strong and eventful history that has provided many
benchmarks for nurses seeking expanded roles. As an
anesthesia provider, the goal of the CRNA is to provide
safe and comfortable anesthesia for all types of surgical
procedures in multiplesettings across the care continuum
for patients of all ages spanning the American Society
of Anesthesiologists (ASA) classifications of healthy
to gravely ill/impending death. In discussing this
broad role definition, the concept of independence is
also clearly expressed, especially because the CRNA
often is able to administer anesthesia without the
direct supervision of a physician, depending on state
regulations and the requirements of the employing
health-care institution. For example, this CRNA stated
that in her practice an anesthesiologist is required to
practice in specified ratios with the CRNA and that
an anesthesiologist must be present in the room at the
start of general anesthesia induction.
The clinical relationship between the CRNA and the
anesthesiologist is clearly described as one of a collegial
and trusting nature with open communication. However, outside of the clinical arena, the political tension
between thetwo disciplines is present with a long history
of debate and interprofessional struggle and competition.
With the demonstration of expertise, however, positive
communication patterns and relationships have developed
Box 12.6
The Nurse Anesthetist

Chapter 12 Mediated Roles 201
around the patient and quality care in institutional
settings. The day-to-day operational framework has
thereby demonstrated advancement over time in terms
of professional acceptance and colleagueship.
Within the operating room, the surgical team assumes a vibrant interdependent structure. This CRNA
stated: Teamwork is the expectation in the operating
room setting. The involvement with RNs, surgeons,
and surgical technologists is intense and very focused
on the individual patient and the procedure at hand
and can sometimes be described as somewhat of an
isolating relationship because of this directed focus.
Regarding the relationship between the CRNA and
RN, it is described as important but less influential in
affecting the role of the CRNA when compared with
the other team members such as the surgeon or technologist. The relationship with surgeons is described as
one of respect for the specialization of anesthesia and
sometimes is dependent during the course of surgery
because the CRNA often leads patient stabilization
efforts when a critical change in condition occurs.
In thespecialty of anesthesia, the CRNA usually does
not make referrals but is the recipient of referrals from
other providers. With theexception of somespecialized
services such as pain management, CRNAs do not have
their own patient caseload becausethe patients primary
relationship is with their surgeon. Consultations, on the
other hand, comprise a major component of anesthesia
practice. Consultations reflect clinical, legal, and medical
aspects of the plan of care. Surgeons frequently request
a consultation from a CRNA, respecting the expertise
of this specialization to assess therisks of surgery. In this
endeavor, the surgeon is dependent on the expertise of
the anesthesia specialist. Within this activity, the CRNA
attains primary patient and family contact, subsequently
establishing the patient-family relationship.
Authority in practiceis significant within thespecialty
of anesthesia. Many other disciplines do not share a
common ground in this specialty: thus my roleis unique
within patient care. The CRNA in this practice comments that she also identifies that through her unique
expertise, the independence and influence of her role
takes hold. Other members of the health-care team
recognize my competence, which directly affects my
sense of autonomy and authority. I am called on to assist
others in their clinical assessment of patients, as well as
the advancement of professional knowledge and skills of
residents and nurse anesthesia students.With this broad
range of influence, my sense of authority is promoted.
The ability of the CRNA to influence change and a
higher order of knowledgein the arenas of perioperative
and perianesthesia practice is strongly affected through
teaching by example, demonstrating competence, and
role modeling professional behaviors to all members of
the health-care team. Using this framework, the CRNA
in this practice identifies that she is able to influence
change and advance knowledge by relying on a clinical
approach rather than an academic approach. In many
practices, however, CRNAs also assume formal faculty
roles within various levels of educational programs
throughout the country.
Although working through other people is an
expectation of any health-care professional role,
interdisciplinary exposure is often more limited for
CRNAs and can potentially contribute to isolation.
Interdisciplinary relationships are strongest within the
perioperative team of the surgeon, anesthesiologist,
nurse, and technologist. Extending this relationship to
other clinical staff and family members is challenging.
In addition, CRNAs are often placed within a separate
administrative structure within the health-care facility
or practice, contributing to the isolation, especially
from other professional nurse colleagues.
Within the context of advanced practice, the goal
of the CRNA is to promote nursing, advance health
care, and ensure a safe and high-quality patient care
experience. As theearliest advanced practicerole, CRNAs
have successfully built a strong presence in health care.
The dynamic interplay of partnerships and interdependence between advanced practice and other team roles in
health care is a professional opportunity. Working with
and through others is the cornerstone of the successful
engagement of the health-care team and endorses the
presence of advanced practice over time.

in Advanced Practice

Evidence-Based Practice
Deborah C. Messecar and Christine A. Tanner
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Describe the relationship between clinical judgment and using the best evidence
to make decisions.
Identify and analyze the elements of research methodology that are critical in
providing evidence for practice settings.
Discuss the advantages and limitations of various types of knowledge.
Demonstrate the ability to access information and evaluate the quality of evidence
relevant to practice settings.
Describe tools and strategies for finding the best and most appropriate evidence to
improve practice.
Communicate search strategy to others.
Identify forces (i.e., ethical, legal, political, cultural, logistical, and economic) that
influence research methodology and interpretation of findings in clinical settings.
Translating evidenceinto practice is a key skill for advanced
practice nurses (APNs). Theincreasing interest in knowledge
translation, the process of moving research into practice and
putting knowledgeinto action, coincides with the growing
engagement in theevidence-based practice(EBP) approach
in which practitioners make practice decisions based on the
integration of the research evidence with clinical expertise
and the patients unique values and circumstances (Straus,
Glasziou, Richardson, & Haynes, 2011). EBP builds on
the process of using knowledge gleaned from systematic
reviews and the results of individual studies, but includes
much more such as evidence from opinion leaders, the
products of reasoning, clinical knowledge from practice
experience, and patient preferences, to name a few (Melnyk &

Chapter 13 Evidence-Based Practice 205
Fineout-Overholt, 2014; Melnyk, Fineout-Overholt,
Gallagher-Ford, & Kaplan, 2012). The importance of
teaching critical appraisal of evidence and knowledge
translation skills has only intensified in APN programs
for several reasons. First, EBP is often not the standard of
care. In many cases patients fail to receive recommended
standards of care or are receiving potentially harmful or
unproven treatment (Fink, Thompson, & Bonnes, 2005;
McGlynn, Asch, & Adams, 2003; Melnyk, Grossman,
et al, 2012; Sung et al, 2003). A second major impetus for
the movement to EBP is the growth of scientific evidence
supporting high-value health care and the development of
methods for integrating the availableevidenceexpeditiously
into guidelines for practice (Arnoff, 2011). Information
technology has also greatly augmented our ability to access
this information. A third factor is that media dissemination of information has made patients increasingly savvy
about different available treatments, enabling them to
ask more informed questions about their illnesses and
care (Amante, Hogan, Pagoto, English, & Lapane, 2015;
Cohen & Adams, 2011). Fourth, the urgency of using
evidence to improve clinical care has been highlighted
by the Institute of Medicine (IOM) reports on the future
of nursing (IOM, 2011) and finding and knowing what
works in health care (IOM, 2008, 2011) as well as prior
reports on quality and safety (IOM, 2001, 2004). Robust
EBP skills applied with expert clinical judgment can help
APNs narrow the gap between research and practice and
improve the quality and safety of care.
The objective of this chapter is to present a view of clinical
judgment and the different patterns of clinical reasoning
and their relationship to translating evidence into practice.
The importance of fostering clinical judgment and critical
thinking in APN education wasemphasized in the Carnegie
Report (Benner, Sutphen, Leonard, & Day, 2010). The
emphasis on clinical judgment in APN education is consistent
with recognizing that knowledgetranslation should include
the complex process of applying the general facts derived
from research in a particular situation, given the patients
circumstances and preferences (Tanner, 2009). Research
on clinical judgment is presented to illustrate how nurses
use reasoning patterns as they assess patients, selectively
attend to clinical cues, interpret these data, and respond
or intervene, and how evidence translation fits into this
process. The role of context, the knowledge and experience
background of the nurse, and the effect of knowing the
patient on these reasoning processes is also described. A
research-based model of clinical judgment (Benner,Tanner,
& Chesla, 2009; Tanner, 2006) is presented to provide
a framework for understanding how the APN can draw
on clinical decision-making skills developed over time in
practice along with new skills in transforming evidence
into knowledge to continuously improve the methods of
care being employed. This model helps guide judgments
about what scientific literature and guidelines are relevant
for the questions at hand and whether the evidence the
APN has to support the assessments, interpretations, and
actions has the utility and relevance to be applied to their
clinical decision making. In addition, tips on how to access
and evaluate research evidence to improve the quality of
the APNs point of care decisions are provided.
Historically, EBP was presented as a new paradigm in
health professions practice (Tanner, 1999). This approach
devalued intuition, the use of clinical opinion based on
experience, and basic scientific rationale as sufficient
grounds for clinical decision making and instead stressed
the examination of evidence solely from clinical research
(Bergus & Hamm, 1995). The aim of EBP defined in this
manner is to reduce wider variations in individual clinicians
practices, eliminating worst practices and enhancing best
practices, thereby reducing costs and improving quality.
This goal and the assumptions underlying what counts
as evidence were troubling to many clinicians (Dearlove,
Rogers, & Sharples, 1996; Mitchell, 1999; Rycroft-Malone
et al, 2004; Smith, 1996). Their concern was that expert
clinical judgment would be replaced by a cookbook
approach to decision making. In response to this criticism,
the definition of evidence-based medicine was revised
to be more comprehensive in its view of what counts as
evidence and what should figure into decisions regarding
patient care. Evidence-based medicine is the use of the best
research evidence in making decisions about the care of
individual patients.To practice evidence-based medicine,
clinicians must integrate their personal clinical expertise
with the best available evidence from systematic research,
the local context of care and the internalevidence generated

206 Unit 3 Competency in Advanced Practice
in collaborative practice inquiry. The discussion of EBP
in this chapter is focused on the search for, synthesis of,
and implementation of research findings in practice and
how this links with use of the APNs clinical judgment.
EBP in this view includes decision making about and
implementation of care practices based on several kinds of
evidence such as findings from the literature, local practice
data, national standards or opinions of recognized experts,
and information on patient preferences. APNs areexpected
to integrate their clinical experience with conscientious,
explicit, and judicious use of research evidence to inform
their clinical judgment and make decisions that maximize
the well-being of their patients.
What is clinical judgment? Almost all health professionals
view clinical judgment as an essential skill. In nursing, the
terms clinical decision making or problem solving and more
recently critical thinking have been used interchangeably
to refer to the same phenomenon, which has been viewed
as a disengaged, analytical, and objective process directed
toward resolution of problems and achievement of clearly
defined ends. However, research on expert practice suggests that clinical judgment is far more complex (Benner,
Tanner, & Chesla, 2009;Tanner, 2006) and incorporates
skills that look more like engaged practical reasoning.
Engaged practical reasoning occurs when the nurse recognizes a pattern by being attuned to subtle changes in
the patients clinical state and other salient information
and then forms an intuitive clinical grasp of the situation
without evident forethought (Benner, Tanner, & Chesla,
2009; Tanner, Benner, Chesla, & Gordon, 1993). This
flexible and nuanced ability to read the clinical situation
is key to interpreting what is going on and responding
appropriately. Knowledge of the illness experience for
both the patient and the family as well as their physical,
social, and emotional strengths and weaknesses are just as
important as clinical features of the disease.
Clinical judgment is thus defined as an understanding
or inference about a patients needs, concerns, or health
problems, followed by the decision to act (or not act), to use
or modify standard approaches, or to improvise new ones
there such as patient assessment, outcomes management,
and quality improvement data and apply this within the
context of their patients unique values and circumstances
(Melnyk, Gallagher-Ford, Long, & Fineout-Overholt,
2014; Rycroft-Malone et al, 2004; Sackett, Rosenberg,
Gray, Haynes, & Richardson, 1996; Straus, Glasziou,
Richardson, & Haynes, 2011).
This revised and updated view recognized individual
clinical expertise, which is defined as the proficiency
and judgment that individual clinicians acquire through
clinical experience and clinical practice as a valid source
of evidence. Increased expertise not only includes more
effective and efficient diagnosis but also more thoughtful
identification and compassionate use of individual patients
predicaments, rights, and preferences in making clinical
decisions about their care (Sackett et al, 1996; Straus et al,
2011). Best available external clinical evidence was defined
as clinically relevant research, which may include basic sciences research but was preferentially from patient-centered
clinical research that focused on the accuracy and precision
of diagnostic tests (including the clinical examination),
the power of prognostic markers, and the efficacy and
safety of interventions. Use of external clinical evidence
should invalidate previously accepted diagnostic tests
and treatments and replace them with new ones that
are more powerful, more accurate, more efficacious, and
safer. External clinical evidence can inform, but can never
replace, individual clinical expertise; this expertise allows
a clinician to decide whether the external evidence applies
to the individual patient at all, and if so how it should be
integrated into a clinical decision. In contrast, internal
evidence is typically generated through practice initiatives
such as outcomes management or quality improvement
projects undertaken for the purpose of improving clinical care in the setting in which it is produced (Melnyk,
Gallagher-Ford, et al, 2014).
The terms EBP and knowledge translation are related
and sometimes used interchangeably. However, knowledge
translation is a larger, more inclusive concept than EBP and
is defined as a process that includes knowledge synthesis
and the tailored dissemination of knowledge inquiry to
improve health and provide more efficient and effective
health services (Straus,Tetroe, & Graham, 2009). Knowledge
translation includes all steps between the creation of new
knowledge and its application. It includes evaluating
practice-based evidence, facilitating EBP, and engaging

Chapter 13 Evidence-Based Practice 207
techniques for a patient who cannot sit up based on ones
past experience or the experience of others is an example
of practical knowledge. Knowledge, both theoretical and
practical, often determines what stands out as important
in a particular situation. Research-based knowledge can
contribute to the clinicians overall knowledge base for
assessing risks. Knowledge helps the clinician observe
selectively. Research directed toward describing phenomena
of concern to the nurse helps provide information about
what cues are highly associated with particular problems.
This allows the nurse, using this knowledge base, to select
data relevant to determining the problems the patient
may be experiencing. Knowledge also guides action and
contributes to the clinicians repertoire of interventions.
An additional essential component of the knowledge
required for clinical judgment is the importance of knowing the individual patient and being able to draw on this
understanding to better predict and anticipate individual
patient responses (Benner et al, 2009; Peden-McAlpine &
Clark, 2002). Clinicians come to clinical situations with
their own perspectives on what is good and right and these
values profoundly influence what they attend to, the options
they consider using, and ultimately what they decide to
do (Benner et al, 2009; Ellefsen, 2004). The clinicians
outlook is not determined by individual notions of right
and wrong but rather is developed through interaction with
others in the practice discipline. For example, the ethic
for disclosure to patients and families or the importance
of comfort in the face of impending death sets up what
will be noticed in a given clinical exchange and will shape
the way in which the clinician responds. Stereotypes and
biases also affect perception.
Good Clinical Judgment Requires
Knowing the Patient and Responding
to His or Her Concerns
In addition to theoretical and practical knowledge, knowledge of the particular patient, both knowing the patients
typical responses and knowing the patient as a person,
is central to good clinical judgment (Haynes, Sackett,
Guyatt, & Tugwell, 2006;Tanner et al, 1993). When the
clinician knows the typical patterns of responses, certain
aspects of the situation stand out as salient and others
recede in importance. Comparing the current picture to
the patients typical picture allows the clinician to make
as deemed appropriate by the patients response (Benner,
Tanner, & Chesla, 2009;Tanner, 2006). Clinical reasoning,
in contrast to clinical judgment, is the thinking process by
which clinicians make their judgments and includes the
process of generating alternatives, weighing them against
the evidence, and choosing the most appropriate course of
action (Benner, Tanner, & Chesla, 2009; Tanner, 2006).
Clinical judgment has been studied from different theoretical
perspectives (Benner,Tanner, & Chesla, 2009; Brannon &
Carson, 2003; Kosowski & Roberts, 2003; Ritter, 2003;
Simmons, Lanuza, Fonteyn, Hicks, & Holm, 2003;White,
2003), with different clinical foci (McCarthy, 2003), and with
different research methods (Benneret al, 2009;Kosowski &
Roberts, 2003; McDonald, Frakes, Apostolidis, Armstrong,
Goldblatt, & Bernardo, 2003; Ritter, 2003; Simmonset al,
2003; White, 2003). From this historical body of literature
on clinical judgment, several general conclusions were drawn.
The Clinicians Background Is More
Influential Than Objective Data
on Clinical Judgment
The clinicians background influences his or her clinical
judgment in a given clinical situation morethan the objective
data at hand. Clinical judgment requires knowledge, which
is abstract, generalizable, and applicablein many situations.
Knowledge required for clinical judgment is derived from
science and theory and grows with experience as scientific
abstractions are filled out in practice. This knowledge is
often tacit and is an important factor in aiding clinicians
to recognize clinical states instantaneously.
The clinicians background includesexperiential learning,
particularly that gleaned from personal clinical experience.
Three types of knowledge play a part in the clinicians perception of a given situation: theoretical knowledge, practical
knowledge, and research-based knowledge. Theoretical
knowledge, which is acquired through understanding of
scientifically derived knowledge and theory, is used in a
particular situation as a specific application of an abstract
rule or principle. The description of techniques for examining the thorax and lungs in a physical assessment text is
an example of theoretical knowledge that may be applied
by the clinician to individual patients. Practical knowledge,
also known as knowledge from clinical experience, is
acquired through working with many patients. Adapting
or revising ones examination of the thorax and lung

208 Unit 3 Competency in Advanced Practice
of the particular situation. The context for practice that
influences decisions to test and treat can include political
and social milieu (Benner et al, 2009; Tanner, 2006) as
well as patient factors such as socioeconomic status (Scott,
Schiell, & King, 1996). Another view is that social judgment or moral evaluation of patients is socially embedded,
independent of patient characteristics, and a function of
the pervasive norms and attitudes of the clinicians in a
given setting (McDonald et al, 2003).
For clinician providers, health care is increasingly
practiced in a context of heightened accountability
(Klardie, Johnson, McNaughton, & Meyers, 2004;
Vincent, Hastings-Tolsma, Gephart, & Alfonzo, 2015).
APNs are expected to demonstrate that they can provide
care that is both clinically and cost effective (DeBourgh,
2001; Facchiano & Snyder, 2013; Vincent et al, 2015;
Youngblut & Brooten, 2001). The struggle for the APN
in this environment is to deliver high-quality cost-effective
care while still incorporating the needs and preferences of
the individual patient (Klardie et al, 2004).
Clinicians Use a Variety of Clinical
Reasoning Patterns Alone
or in Combination
Work in the art of medical decision making has illustrated
that the essence of clinical reasoning eludes understanding
(Sox, Blatt, Higgins, & Marton, 2007). The results of
studies conducted with nurses during the past 20 years
suggest that nurses use a variety of reasoning patterns alone
or in combination (Benner et al, 2009; Tanner, 2006).
The pattern of reasoning used depends on the demands
of the situation, the goals of the practice, the clinicians
experience with similar situations, and the perception of
what makes excellent practice. The reasoning patterns
used are influenced by the nurses knowledge, biases, and
values; the relationship with the patient; and other factors
in the clinical situation.
Analytic Processes
An analytic reasoning pattern is characteristic of a beginners performance or a more experienced clinician when
stumped. Analytic reasoning is characterized by deliberate,
rational thought that includes the generation of alternatives,
weighing against evidence, and evaluating possible courses
of action. Analytic reasoning can be influenced by biases
important qualitative distinctions about how a patients
condition has or has not changed. Knowing the patient
facilitates the provision of individualized care.
Knowing patients is defined as a taken-for-granted
understanding of patients that comes from working with
them, listening to their accounts of their experiences with
illness, watching them closely, and understanding how
they typically respond (Tanner et al, 1993). This tacit
knowledge, which the clinician may not be able to fully
describe to an outside observer, is more than what can
be obtained in formal assessments. Knowing the typical
pattern of responses, certain aspects of a patients situation
stand out as salient, and other aspects of that same patient
situation may recede in importance. Understanding how
this patient responds under these circumstances forms the
basis for the individualized care called for by the IOMs
report (2001) on quality.
The level of involvement with the patient influences
the way the clinician engages in problem solving, the
outcome of the process, and the sense of satisfaction on
the part of the clinician (Benner et al, 2009). Central to
sound clinical decision making is a concern for revealing
and responding to patients as persons, respecting their
dignity, and caring for them in ways that preserve their
personhood. Developing a sense about the right level of
involvement is a skill learned through experience. The
skilled clinician has a good clinical grasp, recognizing both
familiar and individual patterns. The patients responses to
the nurses actions are observed and the nurses reactions are
then modified according to how the patient is responding
(Benner et al, 2009; Tanner, 2006). Clinical grasp and
clinical response are therefore inextricably linked.
Clinical Judgment Is Influenced
by the Context in Which Care Occurs
Neither context noremotions havetypically been accounted
for in most models of rational decision making. Models
of decision making that ignore context, emotion, and the
individuals experience eliminate the possibility of seeing
these as important in clinical judgment. However, from
the work of Benner and colleagues (2009), we know that
judgment occurs in the context of a particular situation,
when the nurse is emotionally attuned to the situation,
meaningful aspects simply stand out as important, and the
choice of responses is guided by the nurses interpretation

Chapter 13 Evidence-Based Practice 209
and interpreting stories. The difference between these
two types of thinking involves how humans make sense
of and explain what they see. Propositional argument is
making sense of a particular by seeing it as an instance of
a general type. Narrative thinking is trying to understand
the particular case. It allows us to acknowledge individuals
values and personal experiences as important sources of
knowledge that inform the evidence base (Rycroft-Malone
et al, 2004). Kleinman has identified the importance of
understanding the narrative component of illness, claiming
that patient narratives may help clinicians direct their
attention not only to the biological world of disease but
also to the human world of meanings, values, and concerns.
Hence, patient narratives help clinicians to focus their
attention not only on the patients disease problems but also
on the meaning of that illness for the particular patient and
on the effect that disease will have on the patients lifestyle
and ways of coping. Hearing the account of an experience
with an illness not only improves the understanding of the
patients overall situation, it helps identify problem-solving
priorities that cannot be made explicit through disengaged
analytical reasoning. Past studies of physicians (Borges &
Waitzkin, 1995; Hunter, 1991) and nurses (Benner et al,
2009; Zerwekh, 1992) have suggested that narrative
reasoning creates deep background understanding of the
patient as a person; consequently, clinicians judgments
can be understood only against this background.
Clinical narratives are a way of teaching and learning
from other care providers and a way of reflecting on and
understanding ones own practice. Dialoguing with others
who have different vantage points will produce knowledge
about clinical situations that helps to limit tunnel vision
and snap judgments. Using narrative as a way of communicating with other health providers leads to learning
how to better identify signs and symptoms in particular
patient populations, knowing specific patients and learning
to recognize how these patients respond, and identifying
clinical experts with whom you can consult (Benner et al,
2009). Discussing your observations and data with more
experienced clinicians enhances clinical judgment. Even
as an experienced nurse, you consult with colleagues,
draw on their perspectives, and benefit from the pooled
experience of other clinicians. Clinical narratives and the
multiple perspectives of skilled clinicians work together
with science and technology to create knowledge that is
both cumulative and reliable.
and stereotypes. Diagnostic reasoning is an example of
analytic thinking. This is a process in which the clinician
attends to presenting signs and symptoms (cues), generates
alternativeexplanations for the cues (diagnostic hypotheses),
collects additional data to help rule in or rule out possible
explanations, systematically evaluates each explanation in
light of the data, and arrives at a diagnosis or inference
about the patients health status. Once sufficient data are
gathered, the process of evaluating hypotheses begins.
Intuition is characterized by immediate grasping of a clinical situation and is a function of familiarity with similar
experiences (Benner et al, 2009). Intuition is a judgment
without a rationale. Researchers speculate that intuition
is a form of pattern recognition in which the practitioner
picks up on cues that are perceived as a whole and are not
arrived at through conscious or linear analytic processes.
Experienced clinicians develop a sense of salience in which
important aspects of a given clinical situation stand out
because of pastexperience with similar situations. Rational
calculation is not required to make use of this form of
reasoning; however, deliberative rationality may be used
to check out the soundness of conclusions derived from
intuition. The role and desirability of intuitive reasoning
patterns continues to be controversial within the nursing
Intuition has been decried as a poor substitute for
science. In this view, intuition is minimized as nothing
more than a special case of inference, drawing on rational
processes that are unconscious and inaccessible (Crow &
Spicer, 1995; English, 1993). Studies in primary care and
the application of EBP indicate, however, that intuition is
a highly valued form of reasoning and plays a vital role in
clinical decision making (Tracy, Dantas, & Upshur, 2003).
Narrative Thinking
Evidence suggests that narratives are an important part
of clinical reasoning (Bruner, 1986; Kleinman, 1988).
Patient narratives provide us with access to understanding
the experience of health and illness. Bruner claims that
human motives, intents, and meanings are understood
through narrative thinking, which he contrasts with paradigmatic thinking that conforms to the rules of logic.
Paradigmatic thinking is thinking through propositional
argument. Narrative thinking is thinking through telling

210 Unit 3 Competency in Advanced Practice
Benner et al, 2009; Rycroft-Malone et al, 2004). Use of
reflection is a habit and a skill that can be cultivated and
developed over time. Through the introspective process of
connecting ones actions to patient outcomes, reflection
has the potential for generating new knowledge (Kuiper &
Pesut, 2004; Ruth-Sahd, 2003).
Model of Clinical Judgment
A research-based model of clinical judgment developed
by Tanner in 1998 and revised in 2006 is presented in
Figure 13.1. There are four key phases in the model.
The first is noticing, in which the clinician develops a
perceptual grasp of the situation at hand. In this phase
the clinicians expectations of the situation are formed
because of his or her knowledge of the patient; clinical
or practical knowledge of similar patients; and textbook
and research-based knowledge. The context of the clinical situation will further influence the initial grasp of
the situation. The second phase depicted in the model is
interpreting. In this phase the clinician forms an understanding of the situation by using one or more reasoning
patterns. Assessments and additional data collection may
be conducted to rule out hypotheses until the clinician
reaches an interpretation that supports an appropriate
response. During the responding phase, the clinician
may act or choose not to act depending on the situation.
Reflecting occurs when the clinician observes the patients
responses to the action taken. Reflection-in-action refers to
the clinicians ability to see how the patient is responding
Clinical reasoning can also include processes that might
be characterized as engaged practical reasoning. Engaged
practical reasoning includes recognition of a pattern, an
intuitive clinical grasp, or a response withoutevident forethought. Conditions of uncertainty are what prompt the
seeking, appraising, and implementation of new knowledge
by clinicians. Uncertainty occurs when the best course of
action to take, or best decision, is not readily apparent.
The openness to accept that there may be different, and
possibly more effective, methods of care other than those
that are currently employed acts as theimpetus to weighing
evidence against expectations, norms, or standards.
Reflection on Practice Is Often Triggered
by a Breakdown in Clinical Judgment
Reflection is defined as a process of thinking about and
exploring an issue of concern triggered by an experience.
For example, clinicians are often troubled by a patient
encounter that did not go well. Reflecting on the meaning
of an experience, making sense of it, and incorporating
it into ones view of self and the world is part of everyday
life. Reflection prompts the clinician to identify new information or alternative perspectives that can be helpful in
future encounters.To engagein reflection, the clinician has
to be able to connect the patients response and outcomes
with specific clinical actions. Narrative is an important
tool of reflection; having and telling stories of ones experience as a clinician helps turn experience into practical
knowledge (Astrm, Norberg, Hallberg, & Jansson, 1995;
Reflection & clinical learning
with patient
Figure 13.1 A model of clinical judgment.

Chapter 13 Evidence-Based Practice 211
information from this source (Melnyk et al, 2012). This
has contributed to the complaint of many clinicians that
the research literature has limited applicability to clinical
practice (McAlister, Graham, Karr, & Laupacis, 1999;
Melnyk et al, 2012; Rycroft-Malone et al, 2004).
In the past, most clinicians considered the research literature to be unmanageable (Gorman, 2001; Melnyk et al,
2012; Melnyk & Fineout-Overholt, 2014; Rycroft-Malone
et al, 2004; Shapiro, 2007, 2010; Williamson, German,
Weiss, Skinner, & Bowes III, 1989). On top of this difficulty, many clinicians do not know how to interpret the
statistical results of the studies they do locate (Melnyk
et al, 2012; Rycroft-Malone et al, 2004; Windish, Huot,
& Green, 2007). If clinical research is to improve clinical
care, it must be relevant, of high quality, and accessible,
and clinicians must have the skills they need to use it.
To address these difficulties, APNs need to build skills
sharpening their focus on the outcomes of care, forming
clear and researchable questions, accessing the literature
and developing strategies for maintaining currency in the
research literature, and interpreting its relevance.
To access the best possibleevidence at the point of clinical
contact, the clinician should work on the development of
several competencies that support EBP.
Competencies That Support
Evidence-Based Practice
Focusing on Outcomes and Context
Evidence-based medicine has been widely promoted as a
means of improving clinical outcomes.To focus on outcomes
in medical decision making, Bergus and Hamm (1995) and
Sox and colleagues (2007) suggest that clinicians use the
following four-step process. First, the clinician forms an
internal mental framework for the decision task, sketching
out the potential treatment options and outcomes. Next,
the variations among the different outcomes are estimated.
In collaboration with the patient and family, the values of
the potential outcomes are considered. The course of action
that, on average, will result in the best outcome is then
chosen. The scientific evidencebase rate information,
sensitivity, specificity, positive predictive value of a positive
test result, and proportion of the population positively
affected by certain interventionsis the information
needed for estimating the likelihood of achieving different
outcomes with different courses of action.
to the actionand adjust the treatment based on that
assessment. Much of this reflection-in-action is tacit and
not obvious. Reflection-in-action with its subsequent
clinical learning completes the cycle, showing that what
clinicians gain from their experience contributes to their
ongoing clinical knowledge development and their capacity
for clinical judgment in future situations.
The model of clinical judgment presented provides a framework for improving the quality of the clinical judgment
used by the APN. First, the model illustrates where in the
process of clinical reasoning the knowledge that might be
obtained by external evidence can be applied. Second, the
model recognizes the value of clinical expertise initially
not accounted for by the original proponents of EBP.
Third, because the model recognizes a broader range of
contextual factors that could affect the patients responses,
it is more inclusive in the types of research that are viewed
as valid. Fourth, because the model incorporates the value
of knowing the patient in the clinical reasoning process, it
supports a model of patient-centered care (IOM, 2001).
Several problems exist with using the research literature
for evidence-based primary care and hospital practice
(Gorman, 2001; Melnyk & Fineout-Overholt, 2014;
Shapiro, 2007, 2010). Clinicians are under increasing
pressure to keep up-to-date and to base their practice more
firmly on evidence, but few feel that they havethe necessary
time or skills to do this (Melnyk & Fineout-Overholt,
2014; Melnyk et al, 2012; Melnyk, Gallagher-Ford, et al,
2014) or that they work in organizational cultures that
support it (Melnyk, Gallagher-Ford, et al, 2014).
Historically, only a small fraction of the total research
literature included efficacy studies of clinical practice
that form the basis for evidence-based medicine (Haynes,
1993; Shapiro, 2010). Few if any studies addressed appropriateness, meaningfulness, and feasibility of health-care
innovations (Shapiro, 2010). Barriers to using research
evidence cited in a recent study included the lack of usable

212 Unit 3 Competency in Advanced Practice
of diagnostic tests, prognostic markers, and interventions.
These elements of evidence used for predicting outcomes
are defined and described in Table 13.1. Several practical
implications can be drawn from review of the definitions of
Straus, Glasziou, Richardson, and Haynes (2011), in their
guidebook on the practice and teaching of evidence-based
medicine, define the best research evidence as patientcentered clinical research into the accuracy and precision
Table 13.1
Information Needed for Estimating the Likelihood of Achieving
Different Outcomes With Different Courses of Action
Core Concept Definition Features
Base rate
The proportion of persons in a given
population who have a particular
disease at a point or interval of time
Useful for health services planning.
May be the only rates available.
Prevalence studies are particularly useful in guiding decisions
about diagnosis and treatment.
Knowing that a patient has a given probability of having a disease
influences the use and interpretation of diagnostic tests.
Base rate
New cases in a specified period Use incidence rates when (a) you are comparing the development
of disease in different population groups; (b) you are
attempting to determine whether a relationship exists
between a possible causal factor and a disease.
Allows you to determine whether the probability of developing
a disease differs in different populations or periods in
relationship to specific causal factors.
Sensitivity Proportion of people with the disease who
have a positive test
Determines the ability of the test to identify correctly those who
have the disease.
The more sensitive a test, the more certain you can be that a
negative test rules out disease.
Specificity Proportion of people without the disease
who have a negative test
Determines the ability of the test to identify correctly those who
do not have the disease.
The more specific a test, the more certain you can be that a
positive test rules in disease.
value of
positive tests
Probability of disease, given the results of
a positive test
Sensitivity and specificity are characteristics of the test itself; however,
predictive values are influenced by how common the disease is.
For diseases of low prevalence, the predictive value of a positive
test goes down sharply.
Absolute risk
Difference in adverse event rates between
the control and experimental group
Is used to help determine the clinical significance of a
treatmentneeded to calculate NNT*
needed to
Number of patients needed to treat to
prevent one additional bad outcome
Calculated by dividing 1 by the absolute risk reduction. NNT
indicates clinical impact of a treatment.
Range of values on either side A 99% confidence interval is interpreted of an estimate as the
range of values within which one can be 99% sure that the
population value lies.
P value Measure of statistical significance Specifies the strength of the evidence.
NNT, number needed to treat.

Chapter 13 Evidence-Based Practice 213
the question is usually asking in general about a disorder.
Finding information to answer background questions is
also relatively easy. Sources of information likely to provide
answers to these questions include textbooks, drug guides
or other reference books, and narrative review articles
summaries of an area or topic written by an expert in the
field (McKibbon & Marks, 2001).
As clinicians grow in experience, they have increasing
numbers of questions about the foreground of managing
patients. Foreground questions are prompted by a precise
need for information about a specific clinical situation. This
skill of framing foreground questions can be improved by
breaking the question down into its component parts. Think
about the subjects or groups involved, what intervention
is being used, and what the outcomes of interest are. The
four key elements of foreground questions are the patient
or problem, the intervention or treatment, the comparison
intervention or treatment, and the outcome of interest
(Melnyk & Fineout-Overholt, 2014; Straus et al, 2011).
Foreground questions typically require more information
sources to adequately supply the answers (McKibbon &
Marks, 2001). For example, questions about treatment
effectiveness are best addressed by evidence from an
RCT design, whereas questions about patients feelings
and perceptions about their illness experiences are better
addressed in studies that use a qualitative design.
Using the Clinical Literature
The clinical literature can be used for regular surveillance or
keeping up-to-date and for problem-oriented searches.To
conduct searches on a regular basis, clinicians need effective
searching skills and easy access to bibliographic databases.
After the answerable question has been identified, use the
population/problem, intervention, comparison, outcome,
time (PICOT) format to help frame the literature search
(Box 13.1). The PICOT format is a particularly useful
framework to help novice searchers organize their electronic database searches (Craig & Smyth, 2007; Melnyk &
Fineout-Overholt, 2014; Shapiro, 2007, 2010; Shapiro &
Donaldson, 2008).
Two types of electronic databases are available. The
first type is bibliographic and permits users to identify
relevant citations in the clinical literature. MEDLINE
and the Cumulative Index to Nursing and Allied Health
Literature are examples of this first sort of database. Google
Scholar ( is a new database
the core concepts in the table. For example, to determine
the predictive value of a test, clinicians need good estimates
of the prevalence or probability of disease in a patient.
A limitation of this approach to bestevidenceis nursings
interest in questions beyond diagnostic tests and interventions
(Jennings, 2000) to include important issues surrounding
the context of care (Rycroft-Maloneet al, 2004). Although
evidence from qualitative exploratory studies is not usually
included in texts on evidence-based medicine, these studies
are helpful for guiding advanced practice decision making.
Appropriateness and meaningfulness, according to Evans
(2003) and the Joanna Briggs Institute (2008), addresses
the psychosocial aspects of care relating to the patients
experiences, their understanding of health and illness, and
the outcomes they hope to achieve from their health-care
encounter. These dimensions of care are best addressed
with nonexperimental research designs, including both
quantitative and qualitative methods (Shapiro, 2010).
Change in health-care delivery environments is difficult
and evidence of effectiveness and appropriateness may not
beenough to overcome problems that surface with change.
In addition to the usual sources of high-level evidence,
such as randomized controlled trials (RCTs), systematic
reviews, observational studies, and interpretive studies
may yield good evidence, especially related to aspects of
organizational culture that could both affect the ease of
acceptance of the new practice and help determine how best
to implement it (Evans, 2003). These studies inform our
decision making by helping us better understand patient
responses. Understanding patient responses is a critical
condition for using reflection to engagein clinical learning.
Asking Answerable Questions
The inability to ask a focused and precise clinical question
can be a major impediment to EBP.To build skill in asking
focused clinical questions, it helps to categorize questions
according to their level of specificity and according to whom
the question applies, the intervention being considered,
and the outcomes of interest.
Clinical questions can be categorized into needs for
background and foreground knowledge (Melnyk &
Fineout-Overholt, 2014; Straus et al, 2011). Background
knowledge is needed when our experience with a condition or problem is limited. Background questions ask
who, what, for whom, why, where, when, and how well?
Framing a background question is relatively easy because

214 Unit 3 Competency in Advanced Practice
devices. Clinicians should also seek out subscriptions to
electronic practice newsletters.
Appraising Evidence From Studies
After evidence has been retrieved, the next step is to
evaluate, or appraise, the evidence for its validity and
clinical usefulness. Appraisal is crucial because it lets the
clinician decide whether the retrieved research literature
is reliable enough to give useful guidance. Because several
published reports lack sufficient methodological rigor
to be reliable enough for answering clinical questions,
guidelines for evaluating literature have been developed
to assist clinicians without extensive research expertise to
evaluate clinical articles.
Box 13.2 shows a typical set of critical appraisal questions for evaluating articles about therapy. These questions
were synthesized from several sources (EBP HealthLinks
and CEBM Web site; Badenoch & Heneghan, 2006;
Straus et al, 2011). Although the questions seem to reflect
common sense, they are notentirely self-explanatory. Some
assistance is required to help clinicians apply them to specific articles and individual patients. The Evidence-Based
Medicine Toolkit (Badenoch & Heneghan, 2006) provides
guidance on how to answer the appraisal questions that
they specifically recommend. Forexample, on the question
that is also becoming more popular. The second type of
database focuses on evidence summaries and takes the
user directly to primary or secondary publications of the
relevant clinical evidence. Examples of this second type
of database include the Cochrane Database of Systematic
Reviews and the American College of Physicians (ACP)
Journal Club, a publication of the ACPsAmerican Society
of Internal Medicine, which abstracts articles on diagnosis,
prognosis, treatment, quality of care, and medical economics. The ACP database has been formatted to make
clinician searching for answers to clinical questions easier
and to help focus searches on the highest rated and most
accessed articles (Haynes, 2008, 2009). These databases are
available online from libraries and from the organizations
themselves via the Internet.
Several tactics can be used to maintain currency in the
research and clinical literature (Vincent, Hastings-Tolsma,
Gephart, & Alfonzo, 2015). With many journals and
library databases, it is possible to set up regular alert notifications when a new article or summary appears on an
identified topic or author. It is also possible to get table of
content notifications from selected journals. Real Simple
Syndication (RSS) feeds are files that Web sites update with
their newest content and are used by many databases like
PubMed and Web of Science, as well as several journals
and news sites. RSS feed aggregators allow you to open
an RSS reader app like Feedly and Feedburner and see
what is new at many sites all in one location. Another
good option is to use Listservs like those offered by the
several institutes at the National Institutes of Health.
Several mobile apps are available to organize and store
PDFs and bibliographic references. Mendeley is a free
application that can store references and articles and then
be retrieved and be accessible by many different types of
P Population or problem of interest
I Intervention or practice of interest
C Comparison intervention or practiceusually
what is currently done
O Outcome of the intervention or practice
T Time frame in which outcome is expected
Box 13.1
PICOT Format
Critical appraisal questions used to evaluate a
therapy article:
Is the study valid?
Was there a clearly defined research question?
Wasthe assignment of patientsto treatmentsrandomized
and was the randomization list concealed?
Were all patients accounted for at its conclusion?
Was there an intention-to-treat analysis?
Were research participants blinded?
Were the groups treated equally throughout?
Did randomization produce comparable groups at
the start of the trial?
Are the results important?
How large is the treatment effect?
How precise is the finding from the trial?
Box 13.2
Appraising Therapy Articles

Chapter 13 Evidence-Based Practice 215
to retrieving evidence. Use of an e-mail alert for the latest
table of contents from selected journals can make this
strategy less time consuming and more effective.
Using Appraising Summaries
Meta-analysis uses statistical techniques to combine results
across studies. Integrative reviews rely on summaries,
logical synthesis, and narrative to characterize findings.
Research-based guidelines center on care of a particular
patient population and specify processes of care associated
with good outcomes. Both HealthLinks and the CEBM
Web sites have links to several sources of summaries.
UpToDate at is updated daily and has
summaries on many clinical topics. BMJ Clinical Evidence
at is regularly updated and has
clearly outlined explicit review criteria posted.
Meta-analysis requires enough studies with sufficient
commonality to provide a valid conclusion. In other
words, studies have to be looking more or less at the
same outcome and the same intervention. Meta-analysis
is often used when several studies have been conducted
but findings were inconclusive. Meta-analyses combine
the statistical results from several studies into one statistic
that can be used to gauge the size of the treatments impact
on the outcome of interest. To do this, first an effect size
is calculated for each finding of interest in the studies
being reviewed. Then a pooled effect size is calculated for
all findings together.
There is controversy about the statistical techniques
and assumptions of meta-analysis. Bias in the combined
analysis is possible if the selection of studies was flawed or
the elimination of methodologically poor studies was not
done using an objective process. There are also inherent
problems with data pooling, especially if the studies are
not similar enough in design, sample size, outcome types,
and forms of the independent variables used. Identifying
weaknesses in this kind of systematic review can be done
by using the guidelines in the Evidence-Based Medicine
Toolkit (Badenoch & Heneghan, 2006) or by using a
similar guide on the HealthLinks or CEBM sites. Once
you have examined the major components of the review,
you can make a judgment about whether you think it is
a high-quality review and whether the findings are valid.
Were research participants blinded? the text gives the
clinician a definition of the term blinding and then might
provide an example that would help the clinician decide
whether the studies he or she was evaluating met this
criteria. In addition to providing a guide for evaluating
therapy articles, the Evidence-Based Medicine Toolkit has
questions for appraising articles on diagnosis, prognosis,
and harm (risks for certain diseases or conditions). The
Evidence-Based Medicine Toolkit is a great resource for
beginners. As with any other skill, expertise and speed
come with practice. The evidence does not automatically
dictate patient care, but it does provide the factual basis
on which decisions can be made.
As APNs begin to build their literature critical appraisal
skills, several Web sites can be accessed to further refine
these skills. The library guide in EBP (http://guides.lib at the University of
Washington includes an EBP section that contains numerous
resources for finding, evaluating, and rating the literature.
In addition to this site, the Center for Evidence-Based
Medicine (CEBM) has the CATmaker critical appraisal
tool (, which
can be downloaded to help the APN create Critically
Appraised Topics (CATs) for the key articles he or she
encounters about therapy, diagnosis, prognosis, etiology/
harm, and systematic reviews of therapy.
Sources of Primary Clinical
and Research Literature
MEDLINE is provided free on the Internet from many
sites and at least one of these, PubMed (http://www, also includes restored search
strategies that are designed to select studies most likely to
be relevant and valid for clinical practice. MEDLINE is
produced by the National Library of Medicine in Bethesda,
Maryland, and is the best-known bibliographic database
of indexed medical literature. MEDLINE is searchable by
medical subject headings and subheadings, as well as by
author, journal, title, and keyword. The journals covered
by MEDLINE are noted for their overall reliability and
quality; however, the articles still must be scrutinized
carefully for their validity and quality as evidence. A hand
search of current journals is still one of the best ways to
find newly published information. However, this is one of
the most time-consuming and labor-intensive approaches

216 Unit 3 Competency in Advanced Practice
Cochrane Collaboration. Links between the Ovid databases
and EBMR allow users to link from a citation to a review
to the full text of that reviewed article and then to other
readings referenced in the article.
The British Medical Journal (BMJ) publishing group
and the ACPsAmerican Society of Internal Medicine
have created Clinical Evidence, the first major attempt to
provide an up-to-date, evidence-based textbook (www Subscribers can choose between
receiving the service online via a handbook titled the
Clinical Evidence Handbook or a combination of the
handbook plus online, as well as via PDA, resources. A free
trial is permitted to allow potential users the opportunity
to explore the usefulness of the service.
The Agency for Healthcare Research and Quality
(AHRQ) National Guidelines Clearinghouse provides
evidence-based information on health-care outcomes;
quality; and cost, use, and access. In examining what works
and does not work in health care, AHRQs mission includes
both translating research findings into better patient care
and providing policy makers and other health-care leaders with information needed to make critical health-care
decisions. Reports compiled by EBP centers are available
on a range of topics and can cover several therapies for a
given condition. By using your browsers Find feature,
you can quickly locate a given topic.
The Cochrane Collaboration produces a structured
database of high-quality systematic reviews of RCTs.
Originally established in Britain, it is presently composed
of numerous centers in several countries. Reviews involve
exhaustive searches for all RCTs, both published and
unpublished, on a particular topic. One limitation of the
database is that the reviews focus mainly on therapies,
although an increasing number of reviews on diagnostic
topics are being developed. The studies are analyzed using
standardized methodology and meta-analysis. The Cochrane
Library, now managed by Wiley, contains high-quality,
independent evidence to inform health-care decision
making. It includes reliable evidence from Cochrane and
other systematic reviews, clinical trials, and more. Cochrane
reviews bring you the combined results of the worlds best
medical research studies and are recognized as the gold
standard in evidence-based health care.
Nursing-specific resources for evidence reviews have
also been developed. The Joanna Briggs Institute (JBI; at, based in Australia, is committed
Integrative Research Review
Integrativeresearch reviews do not use statistical techniques
to summarize results across studies. Rather, they rely on
the logical comparison and synthesis of the reviewer. The
integrative research review method is the research synthesis approach used by most review articles in clinical care
journals. The quality of these reviews and their resulting
conclusions are even more dependent on the reviewers
skill in critical appraisal. High-quality reviews make explicit how studies were selected for review and the rules
that were used to judge the overall evidence. The reviewer
should state whether some studies were weighted more
heavily than others and should provide a rationale for
doing so. If some studies were discounted, this also should
be described. At present, integrative research review is the
only mechanism available for looking at qualitative studies
that address the same topic.
Practice Guidelines
Practice guidelines can includeformal clinical protocols put
forth by a professional organization, clinical paths formed
by a practice group, and research-based recommendations
that translate conclusions of a meta-analysis or an integrative research review into clinical practice conclusions. A
practice guideline should clearly state what the guideline
does and does not cover, for what patient group it was
designed, the options at each decision point, the actions
recommended, and the outcomes associated with each
course of action. There should be a clear description of
the supporting evidence and how it was gathered and
evaluated. Becausethe literatureis alwaysevolving, practice
guidelines should be explicit about how current they are.
The comprehensiveness of the guideline should also be
described. On the HealthLinks site, there is a link to the
EBM toolkit that has a practice guidelines appraisal tool.
Locating Sources of Summaries
Ovid ( has released an integrated literature
service called Evidence-Based Medicine Reviews (EBMR).
This Web-based service includes the Cochrane Database
of Systematic Reviews, Best Evidence, MEDLINE, and
full-text journals. This resource contains full-text reviews
of clinically relevant articles from throughout the medical
literature published in EBMR and ACP Journal Club
and full-text topic overviews published in the Cochrane
Database of Systematic Reviews, which is published by the

Chapter 13 Evidence-Based Practice 217
test, and so on. Once the clinician has weighed the clinical
use of the evidence and determined that implementation
is feasible or desirable, he or she can either implement it
directly in a patients care or use it to develop protocols
and guidelines.
This chapter should not be considered a stand-aloneresource
for learning the principles of EBP. It is almost impossible
to learn how to search effectively and appraise efficiently
without the help of others and without good resources.
Working in groups is the best method to master theseskills.
Share the task of searching and appraising with others.
Use secondary publications such as the Best Evidence text
developed by the BMJ publishing group. Develop a system
for storing work and sharing it with others. Electronic
information storage and retrieval systems are evolving
rapidly, so continued updates in the available technology
are necessary. When evidence is used to inform clinical
judgment, the APN can take advantage of new knowledge
developments so that care can be more individualized,
effective, streamlined, and dynamic.
to evidence translation and use worldwide. JBI produces
evidence summaries and provides guidelines on evidence
application to practice. The Online Journal of Knowledge
Synthesis for Nursing is a peer-reviewed online journal
dedicated to the scientific advancement of EBP in health
care. The journal presents current scientific evidence to
inform clinical decisions and ongoing discussions on
issues, methods, clinical practice, and teaching strategies
for evidence-based practice. Each article is written as a
synthesis of research studies on a single topic and concludes
with practice implications.
Clinical Significance and Appraisal Process
Having identified evidence that is both valid and relevant,
the next step in using the evidence is to make a judgment
about applying the evidence with your patient in your
setting. Box 13.3 provides a list of questions that clinicians
can use to make a judgment about the clinical application
of the research findings. You must determine whether your
patient is sufficiently similar to the study participants for
the results to be applicable. Critical factors that can affect
generalizability include demographics such as race, age, and
gender. Other factors to consider relate to the feasibility of
implementation of the proposed intervention, diagnostic
To determine applicability to practice, answer the
following questions:
Were the subjects similar to patients for whom you
might provide care now or in the future?
Could you base an intervention on the findings of this
external evidence?
Would any intervention you might identify be within
your scope of practice?
What does the body of evidence say about the general
question that motivated the inquiry?
What actions does the body of evidence warrant?
Box 13.3
Clinical Significance Appraisal Process: Questions to Guide Thinking

Advocacy and the Advanced
Practice Registered Nurse
Andrea Brassard
Learning Outcomes
Learning outcomes expected as a result of this chapter:
Demonstrate skills needed to advocate for consumers, families, and public policy
Present health and wellness coaching as a model of advocacy.
Identify examples of advanced practice registered nurse (APRN) advocacy.
The health-care delivery system is a complicated maze of
services with many gates and gatekeepers. Not surprisingly,
consumers often need help navigating their way through
this intimidating maze. The advanced practice registered
nurse (APRN) is well positioned to advocate for individual
consumers and families who confront barriers to getting
the health-care services they need. APRNs can also advocate for systemic changes to remove the barriers. It takes
education, sophistication, and determination to advocate
at both of these levels. This chapter provides the context
for advocacy and advocacy education. Advocacy and health
coaching are described as well as examples of individual,
family, and consumer-driven systems-level advocacy. Nurse
advocates in each of the four APRN roles are highlighted.
Web-based resources for APRN advocacy are provided.
Nursing leaders Florence Nightingale, Sojourner Truth,
Lillian Wald, and Margaret Sanger are testaments to
the nursing professions historic roots in championing
improved health care, especially for the most vulnerable
among us (Mason, Gardner, Outlaw, & OGrady, 2016).
These pioneers advanced human rights, compassionate
care, and lasting societal changes.

Chapter 14 Advocacy and the Advanced Practice Registered Nurse 219
to advocate for themselves for self-care and within the
complicated health-care system. It is a natural extension
of nursing practice (Hess, Dossey, Southard, Luck,
Schaub, Bark, 2013). Health coaching goes beyond patient education; coaches empower clients to set and keep
wellness goals (Swarbrick et al, 2011). Health coaches
acknowledge clients as experts in their own care (Hess,
Dossey, Southard, Luck, Schaub, Bark, 2013). Health
coaches and advocates recognize what an individual is
striving for, identify goals and values, and respect the
persons choices (Thrasher, 2002). Health coaches increase
the options that are available to clients in order to allow
them to exercise control over their lives. Health coaches
are often care coordinators who use their advocacy skills
to help clients negotiate the complex health-care system.
Definitions of advocacy focus on the individual and family
or public policy, suggesting two levels of advocacy for
APRNs. Client-focused definitions of advocacy emphasize
enhancing client autonomy and assisting clients in voicing their values (Connolly, 1999). At the individual and
family client level, the APRN uses a set of skills to help
people identify their needs and obtain services and provides coaching to meet those needs. Public policy-focused
advocacy aims to influence legislators and policy makers to
change laws or policies with the ultimate goal of improving
public health (Taylor, 2016). At the public policy level of
advocacy, the APRN uses many of the same skills needed
at the individual/family leveland some new onesto
advocate for changes in the health-care delivery system itself.
Advocacy at the Individual
and Family Levels
The client-focused definition of advocacy speaks to patient
advocacy, which focuses on individual patients and their
families. The most dominant model for patient advocacy
comes from the counseling paradigm. Burgeoning during
the civil rights and womens movements of the 1960s
and 1970s, nurses were moving past previous modes of
subservience to physicians and institutions to a direct
relationship with the patient. Inherent in that relationship
is the recognition that the nurse has the authority that
Advocacy is derived from the Latin advocatus, which
means one who summons to give evidence (Gates, 1995).
Advocate is a noun and a verbto act for, speak for, plead
for, or defend. Advocacy has been described as informing,
advising, or counseling (Gadow, 1980, 1989; Kohnke,
1982; Mitchell & Bournes, 2000).
The American Nurses Association (ANA) Guide to
the Code of Ethics for Nurses 2015 defines advocacy as
the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for
persons . . . or for an issue (ANA, 2015, p. 37). The ANA
Code of Ethics calls on nurses to promote, advocate for,
and protect patients rights, health, and safety. Advocacy is
based in the fundamental principles of respect for human
dignity, the right to self-determination, and primacy of
the patients interests (ANA, 2015).
Nurse leaders, researchers, and educators have described
philosophical foundations for advocacy (Curtain, 1979),
required skills (Connolly, 1999), and curricula (Jones,
1982). Advocacy is highly desirable, an indicator of excellence in practice, and a domain in advanced practice
nursing (Benner, 1984; Gadow, 1980; Millette, 1993).
Nurses occupy a middle ground between the consumer
and the health-care system, an optimal place to mediate
(Bishop & Scudder, 1990; Stein, Watts, & Howell, 1990).
Historically, advocacy has been linked to the potential
powerlessness of a patient, although the rising power of the
consumer affects our definitions of advocacy (Hewitt, 2002).
Advocacy must be distinguished from paternalism and consumerism (Schroeder & Gadow, 2000). Paternalism is the
commitment to making decisions for the client because the
professional is obligated to impose expertise on behalf of the
person in need. Professionals often presume that a person
in need is incapable of rational judgment. In contrast, consumerism includes the commitment to remain uninvolved in
client decisions. Persons in need are presumed to be capable
of rational judgment and their right to self-determination
must be respected (Schroeder & Gadow, 2000).
A newer model of patient advocacy is health and wellness
coaching. Eileen OGrady, APRN and wellness coach,
empowers clients to take an active role in their own health
(Gardner, 2014). Coaching involves teaching clients

comes with a claim to a scientific body of knowledge that
is not fully accessible to the lay person (Abbot, 1988). The
nurses ethical responsibility is to transfer as much of that
knowledge as possible to the patient and support that person
in making informed choices. Patient advocacy becomes
teaching, nonjudgmental support of the persons choices
and assistance in acting on those choices (Hanks, 2010).
The counseling model is the mainstay of advanced
practice nursing at the individual and family levels. The
more contemporary consumer empowerment model
reminds us that most people do not want or need continual
counseling by professionals. Consumers are breaking away
from the medical model orientation that assumes that
health professionals know what is best to protect patients.
Nurses who define advocacy primarily as protecting patients
(Foley, Minick, & McKee, 2002) may have difficulty with
the contemporary principles of consumer self-advocacy.
Consumers do not seek paternalistic protection. They
do seek professionals who can help them navigate the
system, a high priority for consumers and families who
define advocacy as a go-between who knows the system
and will advise you (Connolly, 1999, p. 390).
The skills and competencies needed by APRN patient
advocates include empathetic listening, self-confidence,
assertiveness, negotiation, collaboration, communication,
physical assessment, mental status assessment, crisis intervention, case management, change agency, and teaching
(Connolly, 1999). Clearly all these skills are within the
scope and education of APRNs. However, paramount
to the success of the patient advocate is a philosophical
foundation that individuals, particularly those who are
vulnerable and suffer from any disease or impairment, are
unique human beings who deserve and require respect,
dignity, and the right to make decisions concerning their
lives. Advocacy for patients and families is a fundamental
part of the nursing process.
Advocacy Exemplar: Individual and Family Level
There are many ways that APRNs can advocate at the
individual and family level. The case example that follows
provides one exemplar.
The complex issues of removing children from their
families and placing them with adoption services while
negotiating a difficult, fragmented child protection system
provides fertile ground and many opportunities for APRNs
to demonstrate their role as advocates. The overburdened,
disjointed systems make it difficult for members of a care
team to understand the complexities of an individual
seeking to regain custody of his or her children. In many
ways, the individual is alone, pitted against a group of
professionals representing the childrenprofessionals
who barely have time to communicate. Negotiating the
system is a complex, difficult endeavor.
Individual and family advocacy can be valuable to individuals attempting to navigate these systems. Vulnerable
populations such as the poor and uninsured, victims of
abuse, single mothers, and individuals with developmental
disabilities or mental illness are in particular need of advocacy services. These individuals are often prohibited from
participating in decisions regarding health care (Schroeder &
Gadow, 2000). Professionals identify themselves as the
expert authority, thereby disempowering the individuals
and destroying the possibility of an equal (or mutual) relationship between an individual and professional. APRN
advocates can counter the effects of this paternalistic system by enhancing personal autonomy and participating
with individuals in determining their needs (Schroeder
& Gadow, 2000).
The Case of Maria
This case study describes Maria and her
involvement in the family court system and
illustrates how an APRN can identify barriers
within a multifaceted system; plan, coordinate,
and monitor services; and follow up with other
advocates within the system.
Maria is a 30-year-old, single mother of four.
Her involvement with the court began several years
ago when her estranged husband abused their oldest
daughter. Maria herself had also been the victim of
his abuse. Although she left her husband shortly
after her daughters abuse, three of her four children
were placed in foster care. The fourth child resided
with Marias mother and Maria participated fully in
this daughters daily life. Maria enjoyed a close and
loving relationship with her intact family, which
included a sister.
Maria was referred to a psychiatric-mental health
APRN by a family court as part of a child welfare
mediation process of planning for the future of
the three children in foster care. Concurrently, the
APRN collaborated with a university law school, a

Chapter 14 Advocacy and the Advanced Practice Registered Nurse 221
Lacey, 1997). The APRN needs to communicate a
sense of hope while establishing realistic expectations
for success to promote client empowerment and
In order to break the coercive control that abusers
have over their victims, nurses need to avoid using
interventions that represent further control of the
victim, thereby perpetuating the cycle of abuse
(Shea, Mahoney, & Lacey, 1997). Advocates must be
wary and avoid paternalistic relationships, exercising
care in understanding the needs and desires of those
in need of their services (Mitchell & Bournes, 2000).
The primary issue preventing Maria from
regaining custody of her children was their safety.
Marias estranged husband had continued to contact
her despite the fact that there was a restraining order
against all contact with her or the children. Maria
felt powerless and clearly did not know how to
react when this occurred. The APRN and university
law school advocates discovered that Maria had
never been provided with a copy of the restraining
order. The university law school advocates obtained
a copy of the order and gave Maria clear, concise
instructions regarding its implementation. In
addition, they arranged for Maria to receive a free
cell phone from a battered womens shelter, enabling
her to call 911 in the event of an emergency. For
additional security, the APRN and Maria located a
safe house and developed an escape plan.
Several other issues were apparent to the APRN
nurse and university law school advocates in
this case. First, before the nurse and law school
involvement, Marias only advocate throughout the
process had been a very caring but overburdened
court-appointed attorney. Although he did
everything he could to assist Maria, time constraints
and the inability to assess Marias cognitive deficits
limited his ability to assist her. On the other hand,
the children had individual case managers, the
Department of Youth and Family Services, the
assistant attorney general, child advocates, individual
therapists, and numerous others working on their
behalf. It was easy to understand why the court and
mediation process were intimidating to Maria and
how they contributed to her feelings of hopelessness
and powerlessness. A second issue that affected
court-appointed mediator, various child protection
case managers, and Marias attorney. The APRN
provided strength-based case management services
(Sullivan, 1991), counseling, and support to Maria
during court-mediated meetings, as well as links to
services identified by the client and nurse.
In addition to attending monthly mediation
hearings over a 6-month period, the APRN met
with Maria weekly. Maria was a quiet, shy young
woman who exhibited developmental and speech
delays. Her affect was depressed and she expressed
feelings of hopelessness and despair. The legal
system had, in fact, determined that three of her
four children would be placed for adoption. Maria,
on the other hand, expressed a strong desire to be
reunited with her family. In particular, Maria wanted
to regain custody of her oldest daughter.
The APRN used the strengths-based case
management model (Sullivan, 1991) in her
assessment. Maria had several strengths. She was
young, relatively healthy, and able to identify solid
family supports. She expressed a fervent desire to care
for her children and demonstrated a willingness to
discuss difficult, painful issues. She expressed a strong
desire to follow the recommendations of the court,
although she sometimes found it difficult to do so.
In addition to reuniting her family, her personal
goals were to obtain a high school diploma and get a
drivers license and a car. The ocean was less than an
hour away and she dreamed of driving to the beach
with her children to see the ocean for the first time.
Initially, Maria did not make eye contact with
the APRN and answered questions only after careful
thought. The nurse construed this to mean that
Maria was searching for the answer she thought the
nurse wanted to hear. Her feelings of powerlessness
and hopelessness were highlighted during the first
mediation meeting when the nurse noted that no one
in the room spoke to Maria. They spoke about and
around her. For her part, Maria sat quietly listening
to the discussion about the future of her family.
Victims of abuse require empowerment and
advocacy (Shea, Mahoney, & Lacey, 1997). Creating
and sustaining a therapeutic caring relationship,
encouraging self-determination, and supporting
patient decisions are essential (Shea, Mahoney, &

preventive policies and programs for abating all houses
with lead paint. Consumers need both levels and APRNs
can be engaged in both levels with different intensity.
Although not all APRNs desire a policy-level advocacy
role, they can support policies and programs that their
nursing colleagues are advancing on behalf of consumers.
The advocacy skills that APRNs need to successfully
advocate for individuals and families are foundational
for systems-level advocacy. Advocacy at this level usually
involves developing new policies, programs, or regulations,
or at least changing the old way of doing things enough
to make a difference for the people that nurses serve.
Communication skills are crucial. Active listening skills
are as important as verbal skills; indeed, more insight is
gained from listening than from speaking. Insight into
the problem leads to more creative problem solving and
ideas for negotiating system solutions. Negotiation is more
complex at the systems level than at the individual and
family levels because generally there are more stakeholders
involved when advocating policies and programs. The
APRN needs to be assertive enough to overcome resistance
to change and collaborative enough to create or join with
others who can help advance the advocacy goal.
To be most effective at the systems level, APRNs need
to understand program and policy development. The
stage-sequential model described by Hanley (2002) can
guide this process. The first stage is identifying a policy
problem and getting that problem placed on the policy
discussion and action agendas in the appropriate forum
(i.e., state or federal legislature, administrative agencies,
funding organizations, and the like). Developing policy
options with supporting budget, infrastructures, and regulations follows. Program implementation and evaluation
are the final stages. Moving through these stages requires
an understanding of the change process in general with
skill development in creating and sustaining a vision for
change, anticipating and dealing with resistance to change,
developing a broad base of support, and understanding
the art of compromise. Systems-level advocacy requires
determination and persistence.
Few APRNs will choose to lead this kind of systems
advocacy. But many will choose to support or resist it. At
a minimum, APRNs need to understand systems advocacy. Systems advocacy involves citizenship and a call for
participation in the decisions that affect our lives and the
lives of those we serve (Joel, 1998; Paquin, 2011).
Marias need for advocacy was that many individuals
involved in her case scheduled her appointments at
overlapping times without consideration for the time
or money required to keep them. In addition, Maria
had difficulty reading, a fact that was unknown to
any of the individuals involved in her case.
The APRN needed to help overcome all these
barriers. Reinforcing her strengths, she helped Maria
find hope tempered with realistic expectations. In
addition to arming her with the restraining order,
cell phone, and escape plan, the APRN helped her
obtain a city bus pass and a color-coded calendar
she could read to help her keep her appointments.
She also helped her enroll in high school general
equivalency diploma classes. This set of advocacy
interventions helped set in motion immediate and
long-term forces of self-empowerment for Maria.
In the end, the court changed its position and
granted Maria custody of her oldest daughter. The
two younger children were placed for adoption in
the foster home they had resided in for several years.
Although Maria was distraught over the loss, she was
able to meet the family, who invited her to remain
involved in the childrens lives.
In this case study, the APRN used Sullivans strengthbased case management model to guide her advocacy
efforts. She identified strengths as well as gaps in the system
and applied practical solutions to overlooked troubles.
The interventions built on Marias strengths, supported
her autonomy, and ultimately enhanced her self-esteem.
Collaborating with child protective services and others
involved in the case created an environment wherein the
advocates identified an opportunity to propose meaningful
interventions and broaden the range of options to Maria
that had long been overlooked by the team.
Systems-Level Advocacy
Systems-level advocacy is nursing practice at the population
or community level. Public health nurses think of it as
upstream thinking. For example, an APRN can treat a
child with lead poisoning and help navigate the child and
his family through specialty clinics and lead abatement
programs case by case. However, a more upstream advocacy
approach would be to prevent lead poisoning through strict

Chapter 14 Advocacy and the Advanced Practice Registered Nurse 223
surveyed about how well they trained family
caregivers, most were very positive. Family caregivers
of patients who had been discharged from the same
settings did not agree (Levine, Halper, Rutberg, &
Gould, 2013). Staff may have indeed given family
caregivers . . . information, but not in a way that
those family caregivers understood and could use
(Levine et al, 2013, p. 20).
In response to the Home Alone report, AARP
developed model legislation to help family caregivers
get the recognition, information, and instruction
they needed to perform the complex medical/
nursing tasks that they were often expected to
perform. The Caregiver Advise, Record, Enable
(CARE) Act required hospitals to ask patients
to designate a caregiver, to notify the caregiver
before discharge, and to educate the caregiver in
medical/nursing tasks they will be expected to
perform (New state law to help family caregivers).
Educating caregivers on medical/nursing tasks
included providing training and the opportunity for
return demonstration of procedures.
Implementing the CARE Act in hospital settings
has been uneven. Although hospitals may identify the
family caregivers on admission paperwork, especially
if they are the next of kin, other aspects of the CARE
Act such as timely notification of discharge are more
difficult to enforce. Educating caregivers on medical/
nursing tasks may only consist of telling. Many
hospitals do not allow anyone other than a hospital
employee to perform medical/nursing tasks on a
hospital patient, so there is no opportunity for return
demonstrations. APRNs in hospital settings have
needed to advocate for institutional policy changes to
allow caregivers to perform procedures such as insulin
administration or tracheostomy suctioning to their
hospitalized loved one (Personal communication,
Sincere McMillan, June 7, 2016).
Chapter 6, Advanced Practice Nurses and Prescriptive
Authority, describes statutory and regulatory barriers
to APRN practice and care (Towers, 2017). Recall from
Consumer-Driven Systems-Level Advocacy
Nurses can lead systems advocacy efforts both as professionals and as consumers. One case example comes from
AARP (formerly the American Association of Retired
Persons). This exemplar is driven by nurses and nurse
advocates working in a consumer organization and illustrates several of the themes in the literature on advocacy,
including the following:
Advocacy is an activity that is not owned by one sector
of health care.
The consumer is an expert.
Advocacy is a partnership between consumers and
Advocacy calls for the development of creative strategies.
Advocacy Exemplar: CARE Act
Most family caregivers perform complex medical/
nursing tasks with very little guidance, according to
a groundbreaking study by the AARP Public Policy
Institute and the United Hospital Fund entitled
Home Alone: Family Caregivers Providing Complex
Chronic Care (Reinhard, Levine, & Samis, 2012).
AARP surveyed family caregivers across the country
to get a look at the type of help they were providing
and found that they were providing much more
complex care than many had thought:
Nearly half were performing some kind of medical/
nursing tasks or medication management.
Most did not get any training to perform these tasks.
Most care recipients did not have home visits by a
health-care professional.
Understandably, family caregivers performing medical/nursing tasks were most likely to report feeling
stressed and worried about making a mistake.
More than half reported feeling down, depressed, or
hopeless in the last 2 weeks, and more than a third
reported fair or poor health. These negative impacts
increased with the number of the care recipients
chronic conditions (Reinhard, Levine, & Samis, 2012).
Family caregivers reported receiving little formal
training in medical/nursing tasks such as managing
medications, performing wound care, or operating
medical equipment, despite patients frequent
hospitalizations. When nurs