APRN Practice 2010 State of the State: Preparation, Regulation, Role, Impact on Quality and Safety Sheila A. Haas, PhD, RN, FAAN Professor, Niehoff School of Nursing Loyola University Chicago Outcomes At the conclusion of this session, participants will be able to: 1.Discuss impact of new regulations on education and the Model for APRN Regulation: Licensure Accreditation, Certification & Education Document (2008) on APRN certification and practice 2.Discuss potential impact of U.S. Patient Protection and Affordable Care Act (Public Law 111-148) on APRN roles, patient safety and costeffectiveness 3.Discuss QSEN Competencies for ARPNs and their impact on role expectations especially in areas of quality and safety 4.Debate issues of concern regarding education, regulation and accountability and expectations for APRNs Definitions (American Board of Nursing Specialties, 2004) Certificationis formal recognition of specialized knowledge, skills and experience demonstrated by achievement of standards identified by a nursing specialty to promote optimal health outcomes Recertificationassures the public that the certificant has maintained a level of knowledge in specialty as well as ongoing participation in activities that support maintenance of competence Benefits of Certification (Drenkard, 2010; Wade, 2009) For APRNs: Personal accomplishment Continued professional development Recognition by third party Opportunities for career advancement Validation of knowledge and skills For Employers: Link to improved quality and patient safety Increased employee competence Employee commitment to their profession Public also views certification as indicator of quality and safety Support for the Development of a New Regulatory Model IOM Report (2001), Crossing the Quality Chasm. Recommends increased coordination and communication among professional boards both within and across states as the patchwork of APRN regulation is resolved over time With national statistics indicating an increasing shortage of both nurses and primary care physicians, state regulation continues to restrain the full scope of practice for APNs. Support for the Development of a New Regulatory Model PEW Health Professions Commission (1998) and IOM Emphasized the need for regulation to be evidence-based, consistent, and protective of patients Wing, O Grady & Langelier (2005). Increase in numbers of APRNs but greatly underutilized due to variable regulation limits in autonomy, and entry into practice relative to skills and potential contribution. Rudner, O Grady, Hodnicki & Hanson (2007). State rankings suggest that wide variations exist in state regulation of advanced practice indicating the strong possibility that in some states, NPs cannot reach their full capacity to care for patients.
Why Develop a Consensus Model for APRN Regulation? Lack of generally accepted definitions of APRN roles Multiple non-equivalent education programs and processes leading to certification Multiple specialties and subspecialties with certification procedures and exams Inconsistencies in state by state recognition of advanced practice roles (Less than 30 states recognize or title protect CNS; not all states license/authorize CRNA same as NP; Summers, 2009) Challenges with determining eligibility for APRN licensure (Summers, 2009, ANA Department of Nursing Practice & Policy) Consensus Model for APRN Regulation (2008) The goalsof the consensus processes were to: Strive for harmony and common understanding in the APRN regulatory community that would continue to promote quality APRN education and practice Develop a vision for APRN regulation, including education, accreditation, certification, and licensure Establish a set of standards that protect the public, improve mobility, and improve access to safe, quality APRN care Produce a written statement that reflects consensus on APRN regulatory issues. (Summers, 2009, ANA Department of Nursing Practice & Policy) APRN REGULATORY MODEL APRN Regulation includes the essential elements: Licensure, Accreditation, Certification Education The LACE APRN Regulatory Model APRN Regulatory Model/LACE Model Licensure is the granting of authority to practice. Accreditationis the formal review and approval by a recognized agency of educational degree or certification programs in nursing or nursing-related programs. Certificationis the formal recognition of the knowledge, skills, and experience demonstrated by the achievement of standards identified by the profession. Education is the formal preparation of APRNs in graduate degree-granting or postgraduate certificate programs. Definition of an Advanced Practice Registered Nurse (APRN) An Advanced Practice Registered Nurse (APRN) is a nurse: 1.Who has completed an accredited graduate-level education program preparing for one of the four recognized APRN roles 2.Who has passed a national certification examination that: a) Measures APRN role b) Population-focused competencies c) Maintains continued competence as evidenced by recertification in the role and population through the national certification program; 3.Who has acquired advanced clinical knowledge and skills to provide direct careto patients, as well as a component of indirect care. a) Defining factor for all APRNsis their education and practice focuses on direct care of individuals; 4.Whose practice builds on the competencies of registered nurses (RNs) by: a) Demonstrating a greater depth and breadth of knowledge b) Greater synthesis of data c) Increased complexity of skills and interventions d) Greater role autonomy Definition of an Advanced Practice Registered Nurse (APRN) Continued: An Advanced Practice Registered Nurse (APRN) is a nurse: 5. Who is educationally prepared to assume responsibility and accountability for: a) Health promotion and/or maintenance b) Assessment, c) Diagnosis, d) Management of patient problems 6. Who has clinical experience of sufficient depth and breadth to reflect the intended license 7. Who has obtained a license to practice as an APRN in one of the four APRN roles
APRN REGULATORY MODEL APRN model of regulation involves four roles: certified registered nurse anesthetist (CRNA) certified nurse-midwife (CNM), clinical nurse specialist (CNS),and certified nurse practitioner (CNP). APRN REGULATORY MODEL APRNs are licensed independent practitioners who are expected to: Practice within standards established or recognized by a licensing body Be accountable to patients, the nursing profession and licensing board and comply with the state NPA Recognize limits of knowledge and experience Plan for management of situations beyond APRN s expertise Consult with or refer patients to other health care providers as appropriate (p. 7). Educational Requirements for APRNs All APRNs are educationally prepared to provide: A scope of services across the health wellness-illness continuum To at least one (of six) population focus Services or care that is defined by patient needs, not limited by setting Educational Requirements for APRNs For entry into APRN practice and for regulatory purposes, APRN education must: Be formal education with a graduate degree (masters or doctoral) or post-graduate certificate (either postmaster s or post-doctoral) Awarded by an academic institution Institution accredited by a nursing or nursing-related accrediting organization recognized by the U.S. Department of Education (USDE) and/or the Council for Higher Education Accreditation (CHEA) Educational Requirements for SONs As part of the accreditation process, all APRN education programs must undergo: A preapproval, pre-accreditation, or accreditation process prior to admitting students. The purpose of the pre-approval process to insure that: graduates from the program will be able to meet the education criteria necessary for national certification in the role and population-focus and if successfully certified, are eligible for licensure to practice in the APRN role/population-focus programs will meet all educational standards prior to starting the program. Educational Requirements for APRNs For entry into APRN practice and for regulatory purposes, APRN education must: Include at a minimum, three separate comprehensive graduatelevel courses (the APRN Core) in: Advanced physiology/pathophysiology, including general principles that apply across the lifespan Advanced health assessment, which includes assessment of all human systems, advanced assessment techniques, concepts and approaches Advanced pharmacology, which includes pharmacodynamics, pharmacokinetics and pharmacotherapeutics of all broad categories of agents. All APRNs in any of the four roles providing care to adults mustbe prepared to meet needs of older adults
Educational Requirements for APRNs For entry into APRN practice and for regulatory purposes, APRN education must include: Additional content, specific to the role and population, in the 3 APRN core areas should be integrated throughout the other role and population didactic and clinical courses Provide a basic understanding of the principles for decision making in the identified role Ensure clinical and didactic coursework is comprehensive and sufficient to prepare for practice in the APRN role and population focus. Foundational Requirements for Certification as APRN (2008) Certification programs providing APRN certification used for licensure will: 1. Follow established certification testing and psychometrically sound, legally defensible standards for APRN examinations for licensure 2. Assess the APRN core and role competencies across at least one population focus of practice 3. Assess specialty competencies, if appropriate, separately from the APRN core, role and population-focused competencies 4. Be accredited by a national certification accreditation body 5. Enforce congruence (role and population focus) between the education program and the type of certification examination 6. Provide mechanism to ensure ongoing competence and maintenance of certification Consensus Diagram 1 Consensus Diagram 2 Relationship between Educational Competencies, Licensure and Certification Competencies Identified by Professional Organizations (e.g. oncology, palliative care, CV) Specialty Measures of competencies Specialty Certification* CNP, CRNA, CNM, CNS in Population context APRN Core Courses: Pathophysiology, Pharmacology, Physical/health assessment Population Foci Role APRN Licensure: based on education and certification (Summers, ANA Department of Nursing Practice & Policy, 2009) (Summers, ANA Department of Nursing Practice & Policy, 2009) Requirements for APRN Specialties An APRN Specialty: Preparation cannot replace educational preparation in the role or one of the six population foci Preparation can not expand one s scope of practice beyond the role or population focus Addresses a subset of the population-focus Title may not be used in lieu of the licensing title, which includes the role or role/population Is developed, recognized, and monitored by the profession. An educational program can prepare individuals concurrently in a specialty as well as the APRN core, role and population core competencies Consensus Document (2009): Impact on Practice Grandfatheringis a provision in a new law exempting those already in or a part of the existing system that is being regulated. When states adopt new eligibility requirements for APRNs, currently practicing APRNs will be permitted to continue practicing within the state(s) of their current licensure.
Impact on Practice - Grandfathering Requirements for reciprocity: If an APRN applies for licensure by endorsement in another state, the APRN would be eligible for licensure if s/he demonstrates that the following criteria have been met: Current, active practice in the advanced role and population focus area, Current active, national certification or recertification, as applicable, in the advanced role and population focus area, Compliance with the APRN educational requirements of the state in which the APRN is applying for licensure that were in effect at the time the APRN completed his/her APRN education program, Compliance with all other criteria set forth by the state in which the APRN is applying for licensure (e.g. recent CE, RN licensure). Implementation of the Consensus Model For APRN Regulation Target Date is 2015 Will require opening of all State Nurse Practice Acts to include new definitions of APRN role, scope of practice, educational, certification and licensure requirements Discussion/Debate What strategies are needed to: Communicate the APRN Consensus Model requirements to APRNs, faculty, academic leadership, students, CNOs in your community and state? Successfully modify your state Nurse Practice Act Who will be key stakeholders? Who will be supporters? How will you elicit support? APRN Consensus Model Toolkit http://www.ana.org This toolkit provides resources to assist in understanding the APRN Consensus Model and learning more about the implementation. Read the APRN Consensus Model http://www.nursingworld.org/consensusmodelforaprn The APRN Committee of the NCSBN has developed a PowerPoint presentation as an educational tool for use by APRN stakeholders. Access it atthe Joint Dialogue Group. Find outwhat the APRN Consensus Model will do for you with this Fact Sheet from National Council of State Boards of Nursing. http://www.ncsbn.org Psych/Mental Health APRNs may wish to review the resources available on the APRNA Web site. For more information about the APRN Consensus Model, read the issue brief, see the PowerPoint presentation, or read the FAQ http://www.nursingworld.org/consensusmodelforaprn Future of Nursing Report Recommendations (IOM, 2010) In 2008, The Robert Wood Johnson Foundation (RWJF) and the IOM launched a two-year initiative to respond to the need to assess and transform the nursing profession. The Future of Nursing Report hasfour key messages: Nurses should practice to the full extent of their education andtraining. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and information infrastructure. (IOM, 2010) Implications of U.S. Patient Protection and Affordable Care Act (PPACA - Public Law 111-148) on APRN Practice Increased numbers of insured and chronically ill with insurance results in increased demand for APRN services both in primary care and specialty care New opportunities for APRN interventions Reimbursement Yearly Wellness Assessment States, establish evidence-based nurse home visitation programs for maternal, infant, and early childhood purposes
Implications of U.S. Patient Protection and Affordable Care Act (PPACA -Public Law 111-148) on APRN Practice Authorizes states or state-designated entities to establish community-based interdisciplinary, interprofessional teamsto support primary care practices within a certain area. Health teams may include nurses, nurse practitioners, medical specialists, pharmacists, nutritionists, dietitians, social workers, and providers of alternative medicine. Health team must support patient-centered medical homes, which are defined as a mode of care that includes personal physicians, whole person orientation, coordinated and integrated care, and evidence-informed medicine. Increase in Medicare Payment for Primary Care Servicesprovides a 10 percent bonus payment under Medicare for fiscal years 2011 through 2016 to primary care practitioners (including nurse practitioners, clinical nurse specialists, and physician assistants) practicing in health professional shortage areas. Certified Nurse-Midwiveswill increase the reimbursement rate for Certified Nurse-Midwives for covered services from 65 percent of the rate that would be paid were a physician performing a service to the full rate. (http://www.nursingworld.org/healthcarereformtoolkit) Implications of U.S. Patient Protection and Affordable Care Act (PPACA -Public Law 111-148) on APRN Practice APRN Opportunities Cont. Create Independence at Homedemonstration program to provide high-need Medicare beneficiaries with primary care services in their home Allow participating teams of health professionals to share in savings from: Reduced preventable hospitalizations Reduced hospital readmissions Improved health outcomes Improved efficiency of care Reduced cost of health care services Increased patient satisfaction. (Effective January 1, 2012) (http://www.nursingworld.org) Implications of U.S. Patient Protection and Affordable Care Act (PPACA -Public Law 111-148) on APRN Practice Support the development of training programs that focus on primary care models Medical homes, APRNs major primary care providers State option under Medicaid to provide coordinated care through a health home for individuals with chronic conditions. Team management of chronic disease Team care models integrate physical and mental health services. Community health centers and school-based health centers Improve access to care by increasing funding (effective fiscal year 2011) Establishing new programs to support school-based health centers (effective fiscal year 2010) Nurse-managed health clinics (effective fiscal year 2010). Trauma care Establish a new trauma center program to strengthen emergency department and trauma center capacity. (http://www.nursingworld.org/healthcarereformtoolkit Discussion/Debate What strategies are needed to get APRNs involved in Health Reform/PPACA opportunities? What do you think will be the APRN response to these opportunities? Who/What entities will take and lead and why? Quality and Safety in Education in Nursing - QSEN History of Development of QSEN IOM Recommendations Knowledge Needed by Nurse Leaders Quality and Safety Education in Nursing (QSEN) http://www.qsen.org (Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner J., Moore, S., Sullivan, D., Ward, D., & Warren, J. (2009). Quality and safety education for advanced practice nurses. Nursing Outlook, 57(6),122-131) QSEN Competencies: Patient Centered Care -Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient s preferences, values, and needs Quality -Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Teamwork and Collaboration ~ Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect and shared decision-making to achieve quality care. Safety ~Minimizes risk of harm to patients and providers through both system effectiveness and individual performance Evidence-based Practice~ Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care Informatics~Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
QSEN APRN Quality Improvement Quality Improvement Knowledge: (Cronenwett, et al., 2009) 1. Describe strategies for improvingthe outcomes of care in the setting in which one is engaged in clinical practice 2. Analyze the impact of context (such as, access, cost or team functioning on improvement efforts 3. Analyze ethical issues associated with quality improvement 4. Describe features of quality improvement projects that overlap sufficiently with research thereby requiring IRB oversight 5. Describe the benefits and limitations of quality improvement data sources, and measurement and data analysis strategies 6. Explain common causes of variation in outcomes of care in the practice specialty 7. Describe common quality measures in practice specialty 8. Analyze the differences between micro-system and macro-system change 9. Understand principles of change management 10. Analyze the strengths and limitations of common quality improvement methods QSEN APRN Quality Improvement Quality Improvement Skills:(Cronenwett, et al., 2009) 1. Use a variety of sourcesof information to reviewoutcomes of care and identify potential areas for improvement 2. Propose appropriate aims for quality improvement efforts 3. Assert leadership in shaping the dialogue about and providing leadership for introduction of best practices 4. Assure ethical oversight of quality improvement projects 5. Maintain confidentiality of any patient information used to determine outcomes of quality improvement efforts 6. Design and use databases as sources of information for improving patient care 7. Select and use relevant benchmarks 8. Select anduse tools (such as controlcharts and run charts) that are helpful for understanding variation 9. Identify gaps between local and best practice 10. Use findings fromroot cause analysis to design and implement system improvements 11. Select anduse quality measures to understand performance 12. Use tools (such as control charts and run charts) that are helpful for understanding variationidentify gaps between local and best practice 13. Use principles of change management to implement and evaluate care processes at micro-system level 14. Design, implement and evaluatetests of change in daily work (using an experiential learning method such as Plan- Do-Study-Act) 15. Align the aims, measures and changes involved in improving care 16. Practice aligning the aims, measures and changes involved in improving care 17. Use measures to evaluate the effect of change QSEN APRN Teamwork & Collaboration Teamwork and Collaboration Knowledge:(Cronenwett, et al., 2009) 1. Analyze own strengths and limitations and values as a member of a team 2. Analyze impact of own advanced practice role and its contributions to team functioning 3. Describe scopes of practice and roles of health care team members 4. Analyze strategies for identifying and managing overlaps in team member roles and accountabilities 5. Analyze strategies that influence the ability to initiate and sustain effective partnerships with members of nursing inter-professional teams 6. Analyze impact of cultural diversity on team functioning 7. Analyze differences in communication style preferences among patients and families, nurses and other members of the health team 8. Describe impact of own communication style on others 9. Describe examples of the impact of team functioning on safety and quality of care 10. Analyzeauthority gradients and their influence teamwork and patient safety 11. Identify system barriers and facilitators of effective team functioning QSENAPRN Teamwork & Collaboration Teamwork and Collaboration Skills:(Cronenwett, et al., 2009) 1. Demonstrates awareness of own strengths and limitations as a team member 2. Continuously plan for improvement in use of self in effective team development and functioning 3. Act with integrity, consistency and respect for differing views 4. Function competently within own scope of practice as a member of the health care team 5. Assume role of team member or leader based on the situation 6. Guide the team in managing areas of overlap in team member functioning 7. Empower contributions of others who play a role in helping patient/family achieve health goals 8. Communicate respect for team member competence in communication 9. Initiate actions to resolve conflict 10. Follow communication practices that minimize risks associated with handoffs among providers, and across transitions in care 11. Choose communication styles that diminish the risks associated with authority gradients among team members 12. Assert own position/perspective and supporting evidence in discussions about patient care 13. Lead or participate in the design and implementationof systems that support effective teamwork 14. Engage in state and national policy initiatives aimed at improving teamwork and collaboration 12. Examine strategies for improving systems to support team functioning QSEN APRN Safety Safety Knowledge:(Cronenwett, et al., 2009) 1. Describe human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds and dangerous abbreviations) 2. Describe the benefits and limitations of selected safety-enhancing technologies (such as, barcodes, Computer Provider Order Entry, medication pumps, and automatic alerts/alarms) 3. Evaluate effective strategies to reduce reliance on memory 4. Delineate general categories of errors and hazards of care 5. Identify best practices for organizational responses to error 6. Describe factors that create a just cultureand culture of safety 7. Describe best practices hat promote patient and provider safety in the practice specialty 8. Describe processes used to analyze causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects 9. Describe methods of identifying and preventing verbal, physical and psychological harm to patients and staff 10. Analyzepotential and actual impact of national patient safety resources, initiatives and regulations QSEN APRN Safety Safety Skills:(Cronenwett, et al., 2009) 1. Participate as a team member to design, promote and modeleffective use of technology and standardized practices that support safety and quality 2. Participate as a team member to design, promote and modeleffective use of strategies to reduce risk of harm to self or others 3. Promote a practice culture conducive to highly reliable processes built on human factors research 4. Use appropriate strategies to reduce reliance on memory (such as. forcing functions, checklists) 5. Communicate observations or concerns related to hazards and errors to patients, families and the health care team 6. Identify and correct system failures and hazards in care 7. Design and implement microsystem changes in response to identified hazards and errors 8. Engage in a systems focus rather than blaming individuals when errors or near misses occur 9. Report errors and support members of the healthcare team to be forthcoming about errors and near misses 10. Participate appropriately in analyzing errors and designing, implementing and evaluating system improvements 11. Prevent escalation of conflict 12. Respond appropriately to aggressive behavior 13. Use national patient safety resources for own professional development and to focus attention on safety in care settingsand design and implement improvements in practice
QSEN APRN EBP Evidence-based Practice Knowledge: (Cronenwett, et al., 2009) 1. Demonstrate knowledge of health research methods and processes 2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values 3. Identify efficient and effective search strategies to locate reliable sources of evidence 4. Identify principles that comprise the critical appraisal of research evidence 5. Summarize current evidence regarding major diagnostic and treatment actions within practice specialty 6. Determine evidence gaps within the practice specialty 7. Analyze how the strength of the available evidence influences the provision of care (assessment, diagnosis, treatment and evaluation) 8. Evaluate organizational cultures and structures that promote EBP QSEN APRN EBP Use health research methods and processes, alone or in partnership with scientists, to generate new knowledge for practice Adhere to Institutional Review Board guidelines Role model clinical decision making based on evidence, clinical expertise and patient/family preferences and values Employ efficient and effective search strategies to answer focused clinical questions Critically appraise original research and evidence summaries related to area of practice Exhibit contemporary knowledge of best evidence related to practice specialty Promote research agenda for evidence that is needed in practice specialty Initiate changes in approaches to care when new evidence warrants evaluation of other options for improving outcomes or decreasing adverse events Develop guidelines for clinical decision making regarding departure from established protocols/standards of care Participate in designing systems that support evidence-based practice QSEN APRN Informatics Informatics Knowledge(Cronenwett, et al., 2009) 1. Contrast benefits and limitations of common information technology strategies used in delivery of patient care 2. Evaluate strengths and weaknesses of information systems used inpatient care 3. Formulate essential information that must be available in a common database to support patient care in the practice specialty 4. Evaluate benefits and limitations of different communication technologies and their impact on safety and quality 5. Describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information systems and knowledge management systems QSEN APRN Informatics Informatics Skills(Cronenwett, et al., 2009) Participate in the selection, design, implementation and evaluation of information systems Communicate the integral role of information technology in nurses work Model behaviors that support implementation and appropriate use of electronic health records Promote access to patient care information for all professionals who provide care to patients Serve as a resource for how to document nursing care at basic and advanced levels Develop safeguards for protected health information Champion communication technologies that support clinical decision-making, error prevention, care coordination and protection of patient privacy Access and evaluate high quality electronic sources of health care information Participate in the design of clinical decision-making supports and alerts Search, retrieve, and manage data to make decisions using information and knowledge management systems Anticipate unintended consequences of new technology Discussion/Debate Who will take a leadership role in bringing current APNs up to speed on QSEN competencies? What challenges/barriers are there to moving all APNs to QSEN APN competencies? How will updating occur? Be measured? What incentives can be used to spur updating to QSEN competencies? References ANA (2010). Health Care Reform Tool Kit http://www.nursingworld.org/healthcarereformtoolkit APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Group (2008). Consensus model for APRN regulation: Licensure, accreditation, certification and education http://www.nursingworld.org/consensusmodelforaprn APRN Consensus Model FAQs (2010). http://www.nursingworld.org/documentvault/aprn- Resource-Section/APRN-Consensus-Model-FAQ.aspx Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner J., Moore, S., Sullivan, D., Ward, D., & Warren, J. (2009). Quality and safety education for advanced practice nurses. Nursing Outlook, 57(6),122-131 Drenkard, K. (2010). Introduction. JONA 40(10), S1-S2. O Grady, E. (2008). Advanced practice registered nurses: The impact on patient safety and quality in Hughes, R. (Ed.), Patient safety and quality: An evidence-based handbook for nurses. http://www.ahrq.gov/qual/nurseshdbk/ Pulcini, J., Jelic, M., Gul, R., & Loke, A. (2010). An international survey on advanced practice nursing education practice, and regulation. Journal of Nursing Scholarship, 42(1) 31-39 Styles, M., Schumann, M., Bickford, C., & White, K. (2008). Specialization and credentialing in nursing revisited. Silver Spring, MD: ANA Wade, C. (2010). Perceived effects of specialty nurse certification: A review of the literature. JONA 40(10), S5-S13