Ruth M. Kleinpell, RN, PhD, FAANP, FCCM Randall S. Hudspeth, PhD (Hons), MBA, MS, APRN-CNP, FRE, FAANP

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1 Issues in Advanced Practice AACN Advanced Critical Care Volume 24, Number 1, pp , AACN Valerie K. Sabol, PhD, ACNP-BC, GNP-BC, CCNS Department Editor Advanced Practice Nursing Scope of Practice for Hospitals, Acute Care/Critical Care, and Ambulatory Care Settings : A Primer for Clinicians, Executives, and Preceptors Ruth M. Kleinpell, RN, PhD, FAANP, FCCM Randall S. Hudspeth, PhD (Hons), MBA, MS, APRN-CNP, FRE, FAANP Advanced practice registered nurses (APRNs), including certified nurse practitioners (CNPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs), represent a growing segment of health care professionals who provide care to patients in various settings. Although opportunities for APRNs are expanding, questions about the specific role components and scope of practice have emerged, especially because APRNs, including CNPs, are assuming greater roles in hospitals, acute and critical care, and ambulatory care settings. The term scope of practice broadly refers to the range of responsibilities that determine the boundaries within which a professional practices. 1 Scope of practice is a term used by state licensing boards for various professions to define the procedures, actions, and processes that are permitted for licensed individuals on the basis of their specific education and experience and their specific demonstrated competency. 2 Education, certification type, licensure, and regulations defined by individual state boards of nursing also shape APRN practice. Yet, variability persists in the degree to which state board of nursing regulations promote APRN practice that is consistent with education, certification, and licensure. The Institute of Medicine s 3 report, The Future of Nursing, highlighted the importance of removing scope-ofpractice barriers to promote the ability of APRNs to practice to the full extent of their education and training. In response to the need to ensure consistency in APRN education and practice, the Consensus Model for APRN Regulation emerged from a national effort to address APRN licensure, accreditation, certification, and education requirements across jurisdictions. The APRN Consensus Model proposes that the requirements for APRNs should be framed in a way that ensures the safety of patients while expanding access to APRN care and promoting a consistent scope of practice. 4 Ruth M. Kleinpell is Director, Center for Clinical Research and Scholarship, Rush University Medical Center, 600 South Paulina Ave, 1062B AAC, Chicago, IL (ruth_m_kleinpell@rush.edu); Professor, Rush University College of Nursing; and Nurse Practitioner, Mercy Hospital and Medical Center, Chicago, Illinois. Randall S. Hudspeth is Chief Clinical and Nursing Officer, Cleveland Clinic Abu Dhabi; and Fellow, Institute of Regulatory Excellence sponsored by National Council of State Boards of Nursing, Chicago, Illinois. The authors declare no conflicts of interest. DOI: /NCI.0b013e31827eeed1 23

2 Issues in Advanced Practice APRN Consensus Model The national Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE), finalized in 2008, defines APRNs and standardized requirements for each of the 4 APRN regulatory components included in LACE. 4 Under the Consensus Model for APRN Regulation, APRNs must be educated, certified, and licensed to practice in 1 of 4 APRN roles: CRNA, CNM, CNP, or CNS. In addition to the 4 roles, APRNs are educated and practice in at least 1 of 6 population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women s health and gender-related health, or psychological/ mental health ( Figure 1 ). 4 Under this model, endorsed by 45 national nursing organizations, APRN practice is based on care that is defined by patient needs. What Does the Consensus Model Mean to the Education and Clinical Practice of APRNs? The APRN Consensus Model outlines implementation issues for APRN education including clarification of education requirements for core coursework, including 3 separate graduate-level courses on advanced physiology/pathophysiology across the lifespan, advanced physical health assessment, and advanced pharmacology, sometimes referred to as the 3 Ps. The APRN Consensus model also outlines the expectation for clinical experiences in the curriculum, highlighting the need for comprehensive experiences to prepare the graduate to practice in the APRN role and population focus. The national consensus based competencies for each of the roles and populations delineate specific expectations, including the length of experiences, patient populations, and settings, to prepare graduates with all of the delineated competencies. Faculty expertise to prepare graduates across the entire adult-older adult spectrum and wellness-illness continuum is also addressed. Other educational components of the Consensus Model include a differentiation of acute and primary care CNP roles for the pediatric and adult-gerontology populations, inclusion of wellness in all APRN curricula, the integration of content related to care of older adults, and preparation of CNSs from wellness to acute care. 4 Figure 1: APRN Consensus Model. Used with permission from APRNReport.pdf. APRN indicates advanced practice registered nurse. a The nurse practitioner (NP) is prepared with the acute care certified nurse practitioner competencies and/or the primary care certified nurse practitioner competencies, which applies only to the pediatric and adult-gerontology NP. Scope of practice of the primary care or acute care NP is not setting specific but is based on patient care needs. Programs may prepare individuals in both primary care and acute care; however, individuals must be prepared with consensus-based competencies for both roles and obtain certification in both. Nurse practitioner certification in the acute care or primary care roles must match the educational preparation for NPs in these roles. 24

3 VOLUME 24 NUMBER 1 JANUARY MARCH 2013 Issues in Advanced Practice A national goal for states to implement the APRN Consensus Model is set for To achieve the 2015 full implementation target, specific projected timelines to implement components of the Consensus Model have been established and are being implemented. First, APRN education programs should be transitioned to integrate the APRN Consensus Model recommendations by 2012 to Accreditation processes should be in place by 2012 to 2013, and new certification examinations are being developed and will be in place by 2013 to 2014, while existing examinations that will no longer be specific to the Consensus Model are being retired, and current certification holders are being appropriately notified of their recertification options. The National Council of State Boards of Nursing reports that 6 states have enacted legislation during the 2012 legislation session that relates to the Consensus Model and 8 states have pending legislation ( Figure 2 ). 5 LACE Network As part of the APRN Consensus Model, the LACE Network was designated to ensure consistency in the education preparation, certification, and licensure requirements for APRNs. The LACE Network was developed as a communication network that includes organizations that represent the LACE components of APRN regulation. The LACE Network provides a mechanism for communicating about APRN regulatory issues, facilitating implementation of the APRN Consensus Model, and involving all stakeholders in advancing APRN regulation. 6 A Web site ( ) has been created to facilitate communication with the entire APRN community and other stakeholders. Competencies As part of the implementation of the APRN Consensus Model, updated competencies were developed to reflect the population and lifespan focus of the APRN role. National task forces were formed and the Adult-Gerontology Primary Care NP Competencies were published in The Adult-Gerontology CNS Competencies were published in and the Adult- Gerontology Acute Care NP Competencies 9 were published in All are available in open access pdf formats on the American 2012 APRN Consensus Model Legislation The below map illustrates which states have introduced or enacted legislation during the 2012 legislative session that relates to the Consensus Model. WA MT ND MN ME OR CA NV ID UT WY CO SD NE KS IA MO WI IL MI IN OH WV KY VA PA NY NJ DE MD VT NH MA CT RI AZ NM TX OK AR LA MS AL TN GA SC NC DC AK HI FL AS VI CNMI GU Enacted Pending Figure 2: State implementation of APRN Consensus Model. Used with permission from the National Council of State Boards of Nursing. 5 25

4 Issues in Advanced Practice Association of Colleges of Nursing Web site ( competencies-older-adults ). Specific to CNP education, certification, and practice, adult-gerontology and pediatric CNPs focus on either primary care or acute care. The adult-gerontology CNP is prepared with either the acute care or the primary care CNP competencies. APRN Scope of Practice A clarifying element of the APRN Consensus Model is the focus on scope of practice, which is designated on the basis of patient care needs and not on a practice setting. The APRN scope of practice is population based and should not be linked to a particular practice setting, such as a hospital or clinic setting. 4, 10, 11 In addition, pre-aprn specialization at the RN level does not extend scope of practice at the APRN level. As an example, an RN who has intensive care unit (ICU) staff nursing experience, and possibly critical care certification, but who completes formal education and training as a primary care NP (adult-gerontology or family NP) is not prepared to practice as an acute care adult-gerontology NP. 10 Although many CNPs have prior ICU experience, their education, APRN license, and certification are focused on primary care, and they would not be prepared to practice as acute care NPs. The individual would need to complete a formal acute care NP educational program (ie, a postmaster s acute care NP certificate program) to practice as an acute care NP. 10 Conversely, an acute care adult or adultgerontology NP who has staff nursing experience in the emergency department, and possibly emergency nursing certification, would not have received education and training at the APRN level to manage pediatric patients with noncomplex problems in an outpatient setting. The CNP would need to complete a formal family or pediatric NP educational program (ie, a postmaster s family NP or a postmaster s pediatric NP certificate program) to have a scope of practice that incorporates care of children. Table 1 outlines a decision aide that can be used to identify scope-of-practice match of patient care needs to NP education, licensure, and certification. The National Organization of Nurse Practitioner Faculties recently developed a statement on the practice of the primary care and the acute care NP practice, which further clarifies NP scope of practice. 10 Table 1: APN Scope of Practice Decision Aide for Hospital, Acute Care, and Ambulatory Care Settings Step 1 Define the need: What are the required APN role components and population foci for the position? Define the scope of the role: A) What will the role encompass in terms of patient care management, health promotion, health protection, disease management, and treatment? B) What competencies will be required for practice? C) What is the anticipated illness acuity level of patients to be managed by the APN? Are the health conditions complex acute, critical, and chronic illness? [Acute care] Are the health conditions acute and chronic where the focus of care is on health restoration or maintenance? [Primary care] D) What interventions/skills/procedures will be required to meet patient care needs? Are the skills that are required focused on lifesustaining therapies such as mechanical ventilation, inotropic support, or lumbar puncture? [Acute care] Are the skills that are required focused on health management therapies of chronic stable nonacute conditions such as joint aspiration, Pap smear, or wound debridement? [Primary care] Step 2 Match the required needs to the APN role A) What is the education, certification, and licensure of the APN? B) What is the scope of practice of the APN as designated by their education, certification, and licensure? Step 3 Determine the APN role for which the patient health care needs, APN education, certification, licensure, and scope of practice designate. Abbreviation: APN, advanced practice nurse. Application to APRN Practice Although the APRN Consensus Model helps clarify education, practice, and certification of APRNs, the concepts of the APRN Consensus Model urgently need to be applied to clinical practice. To apply these concepts, nurse managers and executives who hire and place APRNs, and particularly CNPs, in clinical settings must have a clear understanding of the concepts. Many factors, including uncertainty about APRN roles and scopes of practice, availability 26

5 VOLUME 24 NUMBER 1 JANUARY MARCH 2013 Issues in Advanced Practice of positions, geographic availability of educational programs, and inability of APRNs to relocate to areas where positions specific to their education and preparation are available, have contributed to circumstances in which APRNs may not be in compliance with the APRN Consensus Model. This particularly applies to APRN roles in hospitals and acute care and ambulatory care settings where patient care needs have rapidly evolved and APRNs have been hired to help meet providers staffing deficits and improve patient access. The CNP role most commonly is affected by this type of situation. Ensuring a match between APRN education, licensure, and certification to meet patient health care needs and be congruent with scope of practice is an important consideration for clinicians, executives, and clinical preceptors who can influence APRN role development and role advancement (see Table 1 ). Table 2 outlines 2 clinical examples highlighting decision-making considerations. Examples pertaining to pediatric acute care practice were recently highlighted by Bolick and colleagues. 12 Table 2: Employment Scenarios Example 1 The hospital decides to open a hospitalist program staffed by physicians and NPs. Job description and posting state, licensed NP with full prescription privileges for inpatient hospitalist program. M.S. is an FNP with 1 year of experience in a clinic. Previously, she worked 15 years as an RN in ICU and has a current CCRN certification and is ACLS certified. M.S. interviews for the hospitalist position. Job elements are days with weekend rotation, full range of hospitalized patients not including ICU. Primarily role is medical management of patients admitted for surgery. Decision making evaluation: Qualifications of candidate Job expectations and legal criteria Licensed NP Full prescriptive authority license Past RN experience in ICU Nice to have, has nothing to do with job ACLS and BLS FNP with clinic experience Law is not site specific, so meets criteria Can manage stable and unstable disease in noncritically ill patients. M.S. takes a job in hospitalist program and does well. Soon there is an opening in ICU for a NP. She applies. Decision making evaluation NP qualifications Job requirements RN experience in ICU Nice to have, nothing to do with NP role CCRN Nice to have, no legal value FNP education was primary care, with no clinical time in ICU or acute care Example 2 Could possibly manage the ICU patient but lacks the defined education for this scope As there are no jobs currently available in geographic area, an acute care NP accepts a position to perform intake history and physical examinations, manage medications, and conduct therapy groups in a community mental health center. Decision-making evaluation Qualifications of candidate Job expectations and legal criteria Licensed NP Full Prescriptive Authority License NP education was acute care, with no clinical time in primary care Could conduct H&P and manage medications but lacks the defined education for this scope Abbreviations: ACLS, advanced cardiac life support; BLS, basic life support; CCRN, critical care RN certification; FNP, family nurse practitioner; H&P, history and physical; ICU, intensive care unit; NP, nurse practitioner; RN, registered nurse. 27

6 Issues in Advanced Practice The current health care economic climate dictates that hospitals and other facilities providing care do so in the most cost-efficient manner possible. The increasing number of elderly patients who suffer from multiple and complex diseases and the increasing number of underinsured or noninsured patients presenting for care to emergency departments and outpatient clinics force health care institutions to offer costeffective alternatives. Regardless of the amount of clinical supervision or autonomy allowed within a practice setting, APRNs increasingly are evaluating and treating patients in all settings. Employers are seeking APRNs, especially CNPs, to either augment physician services or independently supplement or replace them because they are cost-effective in terms of lesser salary, with outcomes considered of similar or equal quality In academic centers, integrating CNPs in multidisciplinary provider models is identified as a solution for the decreases in hospital coverage provided by physicians in training following implementation of the Accreditation Council for Graduate Medical Education duty-hour regulations. 18 This demand for CNP provider services in various clinical settings places the burden of appropriate selection and placement on the hiring manager. CNPs must also know their practice limitations in terms of education, certification, and the scope of practice legally authorized by their regulatory board of nursing. Sometimes the burden to fill a vacant position can outweigh making the right match of appropriate education, certification, and experience, which is especially true if the CNP has RN experience in the practice setting. Thus, hiring managers and CNPs should understand the expected outcomes of the Consensus Model to seek and to make appropriate job selections. 19 The unintended consequences of working outside the regulated scope of practice could have devastating effects on both patients and practitioners. The intent of the Consensus Model is to avoid having APRNs who have been employed in positions that may not meet these expectations and who have been providing safe, high-quality care be disenfranchised. Rather, the Consensus Model sets forth a regulatory model to provide consistencies across education, accreditation, certification, and licensure that promotes APRN access and practice. Promoting Adoption of the APRN Consensus Model Table 3 outlines several resources to promote awareness of the APRN Consensus Model, including an APRN Consensus Model toolkit, competency documents, and the LACE Network. Dissemination of these resources to administrators, educators, preceptors, and other stakeholders will help facilitate implementation of the APRN Consensus Model and help advance APRN regulation. They can also serve to provide clarity in job function and help practitioners and employers avoid negative patient outcomes, costly litigation, and possible disciplinary action based on practicing outside the approved scope of practice. Table 3: APRN Consensus Model Resources National Council of State Boards of Nursing s APRN Consensus Model Toolkit: American Association of Colleges of Nursing APRN Consensus Model: education-resources/aprn-consensus-process National Council of State Boards of Nursing APRN Consensus Model Legislation: Adult Gerontology Primary Care Competencies: adultgeroprimcarenpcomp.pdf Adult Gerontology Acute Care Competencies: ACNP-Competencies.pdf Adult Gerontology Clinical Nurse Specialist Competencies: adultgerocnscomp.pdf National Organization of Nurse Practitioner Faculties Statement on Acute Care and Primary Care Certified Nurse Practitioner Practice: APRN-LACE Network Information Site: Abbreviations: APRN, advanced practice registered nurse; LACE, licensure, accreditation, certification, and education. 28

7 VOLUME 24 NUMBER 1 JANUARY MARCH 2013 Issues in Advanced Practice Ensuring that key stakeholders are informed of the recommendations of the APRN Consensus Model remains an important component in securing APRN roles that are matched to education, licensure, and certification. Specific stakeholders such as chief nursing officers are increasingly being challenged to ensure optimal use of APRNs as well as promote supportive environments for building NP teams. Both The Joint Commission and the American Nurses Association Magnet standards, as well as some state statutes, clearly identify the chief nursing officer as responsible for nursing care delivery, even that delivered by an APRN. Clarifying APRN scope of practice and addressing controversy and confusion that continue to exist about APRN scope of practice within hospital, acute care, and ambulatory care settings will help promote the Institute of Medicine s goals of enabling APRNs to practice to the fullest extent of their capacity and by removing barriers to practice. 20 The Future of APRNs Improved patient satisfaction, access, throughput, continuity of care, and physician productivity are frequently cited reasons for the expanding and evolving use of APRNs and CNPs. 21 The advancement of APRN practice requires awareness of the APRN Consensus Model, including requirements for each of the LACE components as well as clarity on APRN scope of practice, to ensure that administrators, educators, preceptors, and other stakeholders are informed about key aspects, including the importance of the match of education, licensure, and certification. Support for implementation of the APRN Consensus Model at the state and national levels remains essential to ensure continued uniformity in APRN practice. REFERENCES 1. Farlex Medical Dictionary. Scope of practice. Accessed October 17, National Council of State Boards of Nursing. Changes in healthcare professions scope of practice: legislative considerations. Accessed November 17, Institute of Medicine of the National Academies. The Future of Nursing. Leading Change, Advancing Health. Washington, DC : National Academy of Sciences ; APRN Consensus Work Group & National Council of State Boards of Nurses. Consensus Model for APRN Regulation: licensure, accreditation, certification and education. Accessed June 10, National Council of State Boards of Nursing. APRN maps. Accessed October 17, LACE Network. Accessed October 15, Expert Panel for Adult-Gerontology Nurse Practitioner Competencies. Adult-Gerontology Primary Care Nurse Practitioner Competencies. Washington, DC : American Association of Colleges of Nursing ; Expert Panel for Adult-Gerontology Clinical Nurse Specialists Competencies. Adult-Gerontology Clinical Nurse Specialist Competencies. Washington, DC : American Association of Colleges of Nursing ; Expert Panel for Adult-Gerontology Acute Care Nurse Practitioner Competencies. Adult-Gerontology Acute Care Nurse Practitioner Competencies. Washington, DC : American Association of Colleges of Nursing ; National Organization of Nurse Practitioner Faculties. Statement on acute and primary care certified nurse practitioner practice. files/acpcstatementfinaljune2012.pdf. Accessed October 15, Kleinpell R, Hudspeth R, Scordo K, Magdic K. Defining NP scope of practice and associated regulations: focus on acute care. J Am Acad Nurse Practit ; 24 : Bolick BN, Bevacqua J, Kline-Tilford A, et al. Recommendations for matching pediatric nurse practitioner education and certification to pediatric acute care populations. J Pediatr Health Care. 2013;27: Hudspeth R. Hospital-based APRNs, financially savvy and revenue generating or a quagmire of issues? Nurs Adm Q ; 35 ( 1 ): Newhouse RP, Weiner JP, Stanik-Hutt J, et al. Advanced practice nurse outcomes : a systematic review. Nurs Econ ; 29 : Mundinger MO, Kane RL, Lenz Er, et al. Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA ; 283 ( 1 ): Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg C, Donahoe MP. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care ; 14 ( 2 ): Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ ; 324 ( 7341 ): Pastores SM, O Connor MF, Kleinpell RM, et al. The ACGME resident duty-hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med ; 39 : Hudspeth R. Balancing need, preparation, and scope of practice: issues impacting behavioral health services by advanced practice registered nurses. Nurs Adm Q ; 31 ( 3 ): Hudspeth R. Helping the chief nursing officer understand nurse practitioners in roles that care for pediatric patients. Nurs Adm Q ; 33 ( 1 ): Moote M, Krsek C, Kleinpell RM, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual ;