Advanced Practice Nursing in

the United States

Joyce Pulcini, PhD, PNP-BC, FAAN, FAANP Professor, George Washington University

School of Nursing April 16, 2015

– High demand for nursing education at all levels

– Second degree programs – Distance Education – Advanced Practice Nursing – Move to Doctoral level

• PhD • DNP (Doctorate in Nursing Practice)

Trends in Nursing

Nursing Education Multiple Pathways

Doctoral preparation—PhD, DNP, DNSc

Advanced Practice RNs and other master’s prepared nurses •  Nursing Practitioner •  Clinical Nurse Specialist •  Certified Nurse Midwife •  Certified Registered Nurse Anesthetists

2 year – associate degree—37.9%

RN 3 year – diploma—6.9% 4 year – bachelor degree- 55%

Licensed Practical Nurse/Licensed Vocational Nurse—I+ year technical

Certified Nursing Assistant—75 hours of training

Figure  25.  Master’s  and  Doctoral  Graduates,  2007  to  2011  

•  Direct  –  Direct  caregiving  –  Holis0c  approach  –  Partnership  with  pa0ents  

–  Evidence-­‐based  pra0ce  –  Expert  clinical  reasoning  and  skill  performance  

•  Indirect  –  Expert  teaching  and  coaching  

–  Consulta0on  –  Scholarly  scien0fic  inquiry  

–  Clinical  and  professional  leadership  

–  Ethical  decision  making  

Direct  and  Indirect  APN  Roles  

Creden<aling  of  Nurses  Specialty Organization Year of First

Certification Nurse Anesthetists AANA (1931) 1941

Nurse Midwives ACNM (1929) 1971

Nurse Practitioners ANA (ANCC) Later AANP, NCC, PNCB

1976

Psychiatric Cl. Nurse Specialists

ANA (ANCC) 1976

History of APN Role in U.S.

•  Precursor Period: 1965-1970 •  Role Definition and Legitimization:

1971-1974 •  Maturation and Consolidation: 1975-1980 •  Maintenance Period: 1981-1990 •  The Expansion Period: 1991-2001 •  Educational Expansion Period: 2002 –

present

In your country, what are the top 3 changes to nurses’ roles and/or responsibilities, e.g., RN, APN, etc., that have improved access to primary health care over the last few years?

•  Future of Nursing Report •  The Affordable Care Act •  New Scope of Practice Laws

Institute of Medicine Report: Future of Nursing (2010)

High-quality, patient-centered health care for all Americans requires a transformation in the health care delivery system New demands on and roles for nurses

1) Nurses should be able to practice to full extent of their education and training

• Remove scope-of-practice barriers

•  Implement nurse residency programs

2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression

•  Increase proportion of nurses with BSN to 80% by 2020

• Double the number of nurses with a doctorate by 2020

• Engage in lifelong learning

3) Nurses should be full partners with physicians and others in redesigning U.S. health care • Expand

opportunities for nurses to lead and diffuse collaborative improvement efforts

• Prepare and enable nurses to lead change to advance health

4) Effective workforce planning and policy-making require better data collection and an information infrastructure • Build an improved

infrastructure to collect and analyze health care workforce data

IOM Recommendations

The Patient Protection and Affordable Care Act of 2010

Primary Health Care and Primary Health Care Providers

•  Increases for primary health care reimbursement

•  Focus on preventative health care •  Promotes Patient Centered Health

Care Homes (sometimes called medical homes)

•  Expanded efforts in: – Chronic disease management – Transitional Care (funding for pilot

studies) – Care coordination (ACOs) –  Independence at home efforts

targeted

Provisions Affecting Nurses and other Health Care Providers in the ACA

•  Increased reimbursement rates for CNMs. •  Enactment in 2014 of a provision to

decrease discrimination by private health plans that might impede use of the services of advanced practice nurses.

•  Creation of the National Health Care Workforce Commission to explore the workforce needs of the nation.

•  Establishment of demonstration grants for nurse residencies and Medicare demonstration programs to fund Graduate Nurse Education. In the past, much of this money went to medical education. (Keepnews, 2010).

ACA continued •  Provide federal funding to support the

development and operation of Nurse Managed Health Clinics (NMHCs) http://www.nncc.us

•  New Health Resources and Services Admin. grants to smooth the progress of interprofessional practice and to advance nursing education.

•  Provider Neutral Language

Community Implications of the ACA •  Expanding community health centers or

establishing new ones in health care provider shortage areas.

•  Funds for School-based health centers •  Expansion of home visitation programs of infants

and mothers such as the Nurse-Family Partnership http://www.nursefamilypartnership.com

•  Additional support for programs that focus on prevention and wellness such as research, screening, immunizations and public marketing

What factors hindered these changes in nurses’ roles and/or responsibilities? e.g., healthcare needs, regulation, economics/funding, education, etc

•  Organized Medicine •  Restrictive regulation •  Faculty shortages and clinical

practice site shortages

The State Practice Environment for NPs •  20 states and the District of Columbia allow NPs to

practice fully under their own license (full plenary authority) including prescriptive authority

http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf

-CT, Nebraska just passed legislation (MD added) •  18 states require physician involvement to

diagnose and treat or prescribe medications, or both •  12 states are considered most restrictive including

MA., Mich., Calif., Fla., VA. requiring supervision, delegation or team care in order for NPs to practice

•  A few states still have joint Regulation by Boards of Nursing and Medicine for APRNs

2015 Nurse Practitioner State Practice Environment  

 Full  Prac0ce  

Reduced  Prac0ce  

Restricted  Prac0ce  

hHp://www.aanp.org/images/documents/state-­‐leg-­‐reg/stateregulatorymap.pdf  

$  

$  

DC  

*  

Shortage of Nurse Faculty (2013) > 8.3% national nurse faculty shortage Faculty age was on average

§  Professor, associate professor, and assistant professor were 61.3 , 57.7, and 51.5 years, respectively.

Retirements §  Average age of nurse faculty at retirement = 62.5 §  200-300 faculty eligible for retirement annually

Years to produce faculty Eased by economic downturn More competitive salaries in clinical settings

§  $94,050 (NP) vs. $80,690 (masters faculty)

hHp://www.aacn.nche.edu/media-­‐rela0ons/fact-­‐sheets/nursing-­‐faculty-­‐shortage      

Salary Differential

Impact of Faculty Shortage Qualified candidates denied admissions

§ ~ 52,212 qualified applicants turned away from undergrad/graduate programs (2012)

§ Nursing shortage Health care services

§ 1 FTE nursing faculty graduates ~ 6 new nurses each year; provide > $720,000 in services annually

§ 94% of AMC CEOs believe faculty shortages are problematic—nursing most severe

What factors enabled these changes in nurses’ roles and/or responsibilities? e.g., healthcare needs, regulation, economics/funding, education, etc.

•  Strong Regulatory Models for APNs •  In Primary Care, increasing numbers of NPs/

decreasing numbers of physicians choosing primary care

•  More population focused care/ chronic disease management

•  Increasing Public Relations focusing on the APNs

APRN REGULATORY MODEL APRN SPECIALTIES

Focus of practice beyond role and population focus linked to health care needs

Examples include but are not limited to: Oncology, Older Adults, Orthopedics, Nephrology, Palliative Care

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ci Family/Individual

Across Lifespan Adult-

Gerontology* Neonatal Pediatrics

é    é     é    é     é     é     é    

POPULATION FOCI

APRN ROLES

Nurse Anesthetist

Nurse- Midwife

Clinical Nurse Specialist

Nurse Practitioner *

Women’s Health/Gender- Related

Psychiatric-Mental Health**

AACN,  2011  

Building a Curricula: LACE Model (AACN, 2011)

APRN

Role

Population foci

Specialty

Regulation

Competencies

3 Ps (Advanced Pathophys, Pharmacology, Health Assessment)

NP, CRNA, CNM CNS Core competencies in Population context

Professional Organizations (e.g. oncology, palliative care, nephrology)

Professional Certification

Graduate Core Master’s or DNP Essentials

Who  is  Providing  Primary  Care?    (Pohl,  2013)  

*Federa<on  of  State  Medical  Boards  Data  2012  **Kaiser  Founda<on:  hNp://kff.org/other/state-­‐indicator/total-­‐nurse-­‐prac<<oners/  ***AAPAs  Vital  Sta<s<cs  2012  Na<onal  Commission  on    Cer<fica<on  of  Physician  Assistants  

AHRQ    (2012)  .  Primary  care  workforce    facts  and  stats  #1,  2.  hNp://www.ahrq.gov/research/pcworkforce.htm  

Total (2013 data)  Percent primary care by

selected clinicians* # Practicing primary care  

Physicians (878,194) Federa0on  of  State  Medical  Boards  Data  

33% 208,807 (2010) 289,804 (2013)

NPs 180,233 Kaiser  Founda0on:  hHp://kff.org/other/state-­‐indicator/total-­‐nurse-­‐prac00oners/

52% - 66% (AHRQ-AANP)

55,625 (2010) 93,721-108,000 (2013)

PAs 86,500 AAPAs  Vital  Sta0s0cs  2012  Na0onal  Commission  on    Cer0fica0on  of  Physician  Assistants  

43.4% 30,402 (2010) 37,541 (2013)

Total 1,144,927 294,834 (2010) 421,070 + (2013) *(AHRQ  (2012).  Primary  care  workforce  facts  and  stats  #2.)

 hHp://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html  

Geo-graphy

NP PA Family physicians

Gen Internal Med

General Peds

US Population

Urban 72.2% 75.1% 77.5% 89.8% 91.2% 80%

Large Rural

11.0% 11.7% 11.1% 6.7% 6.2% 10%

Small Rural

7.7% 6.9% 7.2% 2.4% 1.8% 5%

Remote Rural/ Frontier

9.1% 6.3% 4.2% 1.1% 0.8% 5%

Geographic Distribution of Health Care Professionals in Primary Care, 2010 AHRQ (2012). Primary care workforce facts and stats #3. http://www.ahrq.gov/research/pcwork3.htm

The Issue •  Medical school graduates are not choosing primary care

specialties to an increased degree. •  The ACA has improved access to care for many

Americans thus more primary care is needed.

What is the alternative? This is where expanded scope of practice for nurses and other health professions comes in.

Mary Wakefield, PhD, RN, Acting Deputy Secretary for the U.S. Department of Health and Human Services (DHHS) Surgeon General of the United States Army (December 2011 to present): Patricia D. Horoho, PhD, RN Linda Schwartz, DrPH, RN: Assistant Secretary of Veterans Affairs Ellen Marie Whelan: PhD, RN, Senior Advisor at the Innovation Center in the Centers for Medicare and Medicaid 6 nurses currently serve in Congress,

–  Edie Bernice Johnson (D-TX) –  Lois Capps (D-CA) –  Renee Ellmers (R-NC) –  Carolyn McCarthy (D-NY) –  Karen Bass (D-CA) –  Diane Black (R-TN)

Nurses as Policy Leaders

AANP youtube video

https://www.youtube.com/watch?v=JFKQm1IB-DY&feature=youtu.be