NSG 6006 Study Guide
Policies & Practice Standards • State Nurse Practice Act
NSG6006 Study Guide
5000 (Roles)
• _History and Developmental Aspects of Advanced Practice Nursing
• Definition of advanced practice nurse (APN) - A nurse who has completed an accredited
graduate-level education program preparing her or him for the role of certified nurse practitioner,
certified registered nurse anesthetist, certified nurse-midwife, or clinical nurse specialist; has passed
a national certification examination that measures the APRN role and population-focused
competencies; maintains continued competence as evidenced by recertification; and is licensed to
practice as an APRN
involves advanced nursing knowledge and skills; it is not a medical practice, although APNs perform
expanded medical therapeutics in many roles
• History of APN movement
History and evolution of nursing science
Knowledge development
APN Roles
CNSs have a strong and tumultuous history. Over the past 20 years, the departure from
direct patient care as being a main focus to working predominantly in the nursing education and
systems improvement domains has created confusion within nursing and the public because non-
CNSs (e.g., nurse educators, quality improvement managers) function in the same capacity.
However, CNSs are uniquely educated to provide advanced practice and specialist expertise when
working directly with complex and vulnerable patients, educating and supporting interdisciplinary
staff, and facilitating change and innovation in health care systems that those in other roles in health
care cannot. As health care reform continues to gain momentum to improve the health care system,
there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can
develop new roles to meet the needs of patients and health care systems. For example, in nurse-
managed clinics, perhaps NPs could deliver the primary care to patients in the management of
hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a
referral could be placed to the cardiovascular CNS for specialized pharmacologic and
nonpharmacological treatment. Also, the cardiovascular CNS could integrate the latest evidence to
create educational materials for patients and other health care professionals. Perhaps a CNM who is
caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech
position could ask the perinatal CNS to commonage the patient by following the patient and fetus or
neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal
CNS could establish interagency processes to facilitate care delivery across practice settings to
provide seamless transitions of care. The possibilities are endless if CNSs understand their role,
improve understanding of the importance of this role in advanced practice nursing, and maximize the
driving forces and minimize the restraining forces in the health care system.
Primary care is the foundation of the evolving U.S. health care system. If access to primary
care for all is the goal, while containing costs and focusing on quality outcomes, then NPs will be
crucial to achieving these aims. In our current system, there just aren't enough PCPs to meet the
need and, with an additional estimated 32 million more people who will be covered and need access
to full primary care, based on the PPACA, we will need additional providers more than ever.
Physicians are not choosing primary care practice for complex reasons. On the other hand, most NPs
choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these
programs specifically to provide primary care. Two areas in particular must be addressed before NPs
will be able to contribute fully to primary care delivery nationwide:
1.There must be changes in the outdated state scope of practice laws and regulations of
nurse practitioners. This is because the variation in state regulations on scope of practice and
prescribing authority has been a major barrier to using NPs fully and providing increased access to
quality, cost-efficient primary care.
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, 2.There must be substantive changes in health professional education to foster true
collaboration and teamwork among physicians, NPs, and other health care disciplines in general to
obtain the full benefit of diverse competencies inherent in a team.
If both of these are addressed, meeting U.S. primary care needs could be significantly
affected in a positive way. Today's NP students and graduates must accept the professional
responsibility for being active in the governance of delivery systems and informing and changing
policy. There is too much at stake to leave this to a few, or to someone else. The health of the United
States population depends on new models of care, on all health care providers practicing to the
fullest extent of their education and training, and on strong teams who respect each other and partner
with patients. NPs must support their efforts as they take an active role in developing stable health
care policy and care delivery systems that allow for patient access to primary care services provided
by NPs.
The ACNP role provides an opportunity for NPs to have a significant impact on patient outcomes at a
dynamic time in the history of health care delivery. As their role continues to evolve, and as health
care systems respond to market forces and economic change, opportunities to develop the ACNP
role further will arise. Future development of the ACNP role should be based on the evaluation of the
need for the role, understanding the scope of the role, assessment of the practice or organization,
and the service needs of the patient population. Ensuring that ACNPs practice to the full scope of
their education and training is in alignment with the recommendations of the Institute of Medicine
(2011). Because the ACNP role continues to evolve, participation in national organizations to refine
consensus regarding role components, program curriculum, marketing, and role evaluation is
necessary. ACNP educators and clinicians must work together to ensure that the preparation and
practice of ACNPs is safe, effective, and fully represented as the movement of doctoral APN
education evolves. ACNPs must be strong activists in efforts to gain full recognition of their role within
their proper scope of practice across acute care settings. In this evolving health care arena, ACNP
practice is rapidly expanding and holds unlimited potential. Ongoing challenges include ensuring
expansion of the ACNP with a focus on advanced practice nursing, rather than as a physician
replacement model of care.
Nurse-midwifery practice encompasses a full range of primary health care services for
women, from adolescence beyond menopause. These services include the independent provision of
primary care, gynecologic and family planning services, preconception care, pregnancy care,
childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and
treatment of male partners for sexually transmitted infections. CNMs provide initial and ongoing
comprehensive assessment, diagnosis, and treatment. They conduct physical examinations,
prescribe medications, including controlled substances and contraceptive methods, admit, manage,
and discharge patients from birth centers or hospitals, order and interpret laboratory and diagnostic
tests, and order the use of medical devices. CNMs' care also includes health promotion, disease
prevention, and individualized wellness education and counseling. CNMs must demonstrate that they
meet the core competencies for basic midwifery practice of the ACNM (ACNM, 2008b) and must
practice in accordance with the ACNM standards for the practice of midwifery (ACNM, 2011d). With
constant changes in health care, CNMs may need to expand their knowledge and skills beyond that
of basic CNM practice. Advanced CNM skills, such as level 1 ultrasound or acting as first assistant in
surgery, may be incorporated into a CNM's practice as long as the CNM follows the
recommendations for acquiring these skills by obtaining formal didactic and clinical training to ensure
that the advanced skill is acquired and monitored to ensure patient safety.
There have been many recent positive advances in nurse-midwifery and between nurse-midwifery
and the broader health care system. The ACNM has been reaching out to professional nursing,
midwifery, medical, policy, and public health colleagues nationally and internationally. There has
been international recognition of the need for more midwives to reduce maternal and neonatal
mortality. In the United States, the IOM report, the Future of Nursing, and passage of the PPACA has
placed CNMs and other APRNs in a partnership role in redesigning the health care system for the
future. From a midwifery perspective, we hope that this system will honor women and offer them
support in realizing the power that comes with the choice of a woman-centered health care system.
Nurse anesthesia, the earliest nursing specialty, was also the first nursing specialty to have
standardized educational programs, a certification process, mandatory continuing education, and
recertification. Nurse anesthetists have been involved in the development of anesthetic techniques
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,along with physicians and engineers. CRNAs have been nursing leaders in obtaining third-party
reimbursement for professional services and in coping with challenges such as the prospective
payment system, managed care, and physician supervision. Nurse anesthetists provide surgical and
nonsurgical anesthesia services in a variety of settings in the United States and other parts of the
world. CRNAs work collaboratively with physicians, as do other APNs, and are capable of providing
the full spectrum of anesthesia services. Activism at the state and federal legislative and regulatory
levels is a recognized CRNA activity. Increasing coalition building among nurse anesthetists, other
APNs, and nursing educators is congruent with a shared nursing vision. This vision values health
care for all Americans, provided in a safe and cost-effective manner by APNs collaborating with other
health care professionals. John F. Garde was a distinguished health care leader who served as
AANA Executive Director from 1983 to 2001, and again on an interim basis from February 2009 until
his untimely death in July 2009. A statement of his holds true today (Garde, 1998, p. 15): The
profession has an optimistic future. I point out with pride the commitment that AANA members have
toward the future of their profession—a commitment that encompasses being outstanding anesthesia
practitioners who belong to their Association. I am reminded, too, what Dick Davidson, President of
the American Hospital Association, said when asked about what will remain in health care 100 years
from now: ‘There will always be personal contact and caring. We will always have hands touching
patients. Everything we do is about human need. That's the constant over time.’ And, that is the
legacy of the nurse anesthesia profession.
SCOPE OF PRACTICE
scope of practice describes practice limits and sets the parameters within which nurses in the various
advanced practice nursing specialties may legally practice. Scope statements define what APRNs
can do for and with patients, what they can delegate, and when collaboration with others is required.
Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice
(American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al.,
2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice
statements are key to the debate about how the U.S. health care system uses APRNs as health care
providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who
administer general anesthesia, have a scope of practice markedly different from that of the primary
care nurse practitioner (NP), for example, although both have their roots in basic nursing. In addition,
it is important to understand that scope of practice differs among states and is based on state laws
promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo,
O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of
practice statements can be found by searching state government websites in the areas of licensing
boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site
(www.ncsbn.org). Recent federal policy initiatives, including the IOM Future of Nursing Report,
(2011). the PPACA (HHS, 2011), and the Josiah Macy Foundation (Cronenwett & Dzau, 2010) have
all issued recom mendations with important implications for expanding the scope of practice for
APRNs. The National Health Policy Forum
(http://www.nhpf.org/library/background-papers/BP76_SOP_07-06-2010.pdf) and Citizen Advocacy
Center (https://www.ncsbn.org/ReformingScopesofPractice-WhitePaper.pdf) reports state firmly that
current scope of practice adjudication is far too technical, subject to political pressure, and therefore
not appropriate in the legislative sphere. There must be a more powerful forum so that the public can
enter into the dialogue (see Chapter 22). As scope of practice expands, accountability becomes a
crucial factor as APRNs obtain more authority over their own practices. First, it is important that
scope of practice statements identify the legal parameters of each APRN role. Furthermore, it is
crucial that scope of practice statements presented by national certifying entities are carried through
in language in state statutes (Buppert, 2012). Our society is highly mobile and APRNs must
recognize that their scope of practice will vary among states; in a worst case scenario, one can be an
APRN in one state but not meet the criteria in another state.
1.Throughout the century, APNs have been permitted by organized medicine and state legislative
bodies to provide care to the underserved poor, particularly in rural areas of the nation. However,
when that care competes with physicians' reimbursement for their services, there has been
significant resistance from organized medicine, which resulted in interprofessional conflict.
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, 2.Documentation of the outcomes of practice helped establish the earliest nursing specialties and
continues to be of critical importance to the survival of APN practice.
3.The efforts of national professional organizations, national certification, and the move toward
graduate education as a requirement for advanced practice have been critical to enhancing the
credibility of advanced practice nursing.
4.Intraprofessional and interprofessional resistance to expanding the boundaries of the nursing
discipline continue to recur.
5.Societal forces, including wars, the economic climate, and health care policy, have influenced APN
history.
• _Scope of practice cont.
The term scope of practice refers to the legal authority granted to a professional to provide and be
reimbursed for health care services. The ANA (2010) defined the scope of nursing practice as “The
description of the who, what, where, when, why, and how of nursing practice.” This authority for
practice emanates from many sources, such as state and federal laws and regulations, the
profession's code of ethics, and professional practice standards. For all health care professionals,
scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes
are the nurse practice acts of the various states. As previously discussed, APN scope of practice is
characterized by specialization, expansion of services provided, including diagnosing and
prescribing, and autonomy to practice (NCSBN, 2008). The scopes of practice also differ among the
various APN roles; various APN organizations have provided detailed and specific descriptions for
their particular role. Carving out an adequate scope of APN practice authority has been an historic
struggle for most of the advanced practice groups (see Chapter 1) and this continues to be a hotly
debated issue among and within the health professions. Significant variability in state practice acts
continues, such that APNs can perform certain activities in some states, notably prescribing certain
medications and practicing without physician supervision, but may be constrained from performing
these same activities in another state (Lugo, O'Grady, Hodnicki, & Hanson, 2007).
The Consensus Model's proposed regulatory language can be used by states to achieve consistent
scope of practice language and standardized APRN regulation (NCSBN, 2008).
A scope of practice is a state-based legal framework (i.e., statutes, codes, and regulations) that
defines who is authorized to provide clearly delineated services, to whom and under what
circumstances those services can be provided, and who can be reimbursed for those services. All
health professions have an autonomous domain of practice and a delegated authority within the
medical domain (Lyon, 2004). The autonomous domain of nursing practice “encompasses the
diagnosis of health conditions (e.g., nursing diagnoses) that are amenable to nursing interventions
[and] therapeutics, the implementation of interventions, and evaluation of the effectiveness of nursing
interventions [and] therapeutics” (Lyon, 2004, p. 9). Historically, the medical profession developed a
broad, overarching scope of practice that encompassed almost all health care activities (see Chapter
1; Safriet, 2010). As a consequence, other health professionals (e.g., nurses, physical therapists,
pharmacists) have had to carve out their scopes of practice out of the medical scope of practice. The
ANA's restrictive 1955 definition of nursing reinforced the practice of nursing as having independent
functions and being dependent on and delegated to by the profession of medicine. It also prohibited
nurses from diagnosing and prescribing.
By definition, the term scope of practice describes practice limits and sets the parameters within
which nurses in the various advanced practice nursing specialties may legally practice. Scope
statements define what APRNs can do for and with patients, what they can delegate, and when
collaboration with others is required. Scope of practice statements tell APRNs what is actually
beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert,
2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN
roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S.
health care system uses APRNs as health care providers; scope is inextricably linked with barriers to
advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice
markedly different from that of the primary care nurse practitioner (NP), for example, although both
have their roots in basic nursing. In addition, it is important to understand that scope of practice
differs among states and is based on state laws promulgated by the various state nurse practice acts
and rules and regulations for APRNs (Lugo, O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012;
Pearson, 2012). On the Internet, scope of practice statements can be found by searching state
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