The Politics of Advanced Practice Nursing




The Politics of Advanced Practice Nursing



Eileen T. O’Grady and Loretta C. Ford



“We shall be what we determine to be.”


—Margareta Madden Styles, Nurse leader and legend (1930-2005)


Advanced Practice Registered Nurses (APRNs) have achieved unprecedented growth and recognition over the last four decades; political activism and social justice have always been at the heart of all four APRN roles. This chapter explores the major political issues facing APRNs with suggestions from the authors about ways to increase their political competence, visibility, and political power to impact the larger health policy context.


APRN Definition


The term Advanced Practice Registered Nurse is an umbrella term comprising four advanced practice nursing roles: nurse anesthetists, clinical nurse specialists, nurse midwives, and nurse practitioners. APRNs are licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. Although all APRNs are educationally prepared to provide care to patients across the health wellness-illness continuum, the practice emphasis within each APRN role varies. The defining factor for all four APRN roles is that a significant component of the education and practice focuses on the direct care of individuals Box 51-1 (National Council of State Boards of Nursing [NCSBN], 2008).



The Political Issues


Until 2008, there were no common standards for state licensing for APRNs. While education, accreditation, and certification are necessary components of an overall approach to preparing APRNs for practice, the state licensing boards are the final arbiters of who is recognized to practice within a given state. Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry, and the certification examinations required. A consensus among all of the various stakeholders was needed to establish stronger internal cohesion within the APRN movement. This high degree of variability around practice created significant barriers for APRNs to easily move from state to state, decreased access to care, and created confusion among policymakers. Barriers to practice in many states include: requiring physician supervision, limiting reimbursement, and restricting prescriptive privileges (Pearson, 2010). The lack of national standards has made APRNs vulnerable to criticism from those who oppose their independence, such as the AMA. There was much disagreement in the APRN community about the definition of APRNs. For example, clinical nurse specialists (CNSs), who blend advanced practice and specialty nursing practice, have a high degree of variability in their educational programs. They did not uniformly define their role as direct care providers; most are not nationally certified and often do not have a standardized curriculum (Gray, 2001). Certified Nurse Midwives (CNM) created another quandary. They include non-nurses, under the rubric of “midwives” since they credential non-nurse midwives. This decision allows midwives to practice in 14 states provided they hold a bachelors degree, complete an education program in midwifery, and pass a certification exam (Gray, 2001). The practice and/or educational variability of CNSs and CNMs to be included under the APRN umbrella created a particular challenge. As any practice field evolves, a common language is required for guiding and evaluating practice, standardizing educational programs and certification requirements so that states can create sensible regulations to protect public safety.


The history of physician opposition to APRNs is a long one, but was not present when the first NP program was developed, according to Loretta Ford. The early partnership between nurse practitioners (NPs) and pediatricians was built on mutual respect, collaboration, and shared values and goals for patients. However this relationship deteriorated into turf battles as medical organizations sought to control the NP’s expanding scope of practice. The belief that physicians were “Captains of the Ship” fueled a growing animosity between nursing and medical organizations.


Politics introduces divisive and self-interested agendas into the policymaking process. This resistance to APRNs by some organized physician groups is a quintessential definition of politics—the struggle for ascendency or dominance among groups with different power relationships and agendas. One strategy to level the playing field is for organizations to use the power of government to achieve what they cannot alone.


A Common Licensure: LACE


It is within this context that APNs have made a significant achievement with the publication of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (hereafter referred to as LACE) (NCSBN, 2008). This document and the 3-year process that brought together over 70 organizational stakeholders is one of the most important, cutting-edge, and visionary achievements in decades Box 51-2. The LACE document establishes clear, professionally-endorsed, national expectations for APRN licensure, accreditation, certification, and education (Stanley, 2009). It has strengthened the position of APRNs to confront resistance. It creates clear national standards for state regulators to adapt a framework for modernizing their state nurse practice acts across the nation.



BOX 51-2


Organizations Participating in the APRN Consensus Process











1. Academy of Medical-Surgical Nurses


2. American College of Nurse-Midwives Division of Accreditation


3. American Academy of Nurse Practitioners


4. American Academy of Nurse Practitioners Certification Program


5. American Association of Colleges of Nursing


6. American Association of Critical Care Nurses Certification


7. American Association of Neuroscience Nurses


8. American Association of Nurse Anesthetists


9. American Association of Occupational Health Nurses


10. American Board for Occupational Health Nurses


11. American Board of Nursing Specialties


12. American College of Nurse-Midwives


13. American College of Nurse-Midwives Division of Accreditation


14. American College of Nurse Practitioners


15. American Holistic Nurses Association


16. American Nephrology Nurses Association


17. American Nurses Association


18. American Nurses Credentialing Center


19. American Organization of Nurse Executives


20. American Psychiatric Nurses Association


21. American Society of PeriAnesthesia Nurses


22. American Society for Pain Management Nursing


23. Association of Community Health Nursing Educators


24. Association of Faculties of Pediatric Nurse Practitioners


25. Association of Nurses in AIDS Care


26. Association of PeriOperative Registered Nurses


27. Association of Rehabilitation Nurses


28. Association of State and Territorial Directors of Nursing


29. Association of Women’s Health, Obstetric and Neonatal Nurses


30. Board of Certification for Emergency Nursing


31. Council on Accreditation of Nurse Anesthesia Educational Programs


32. Commission on Collegiate Nursing Education


33. Commission on Graduates of Foreign Nursing Schools


34. District of Columbia Board of Nursing


35. Department of Health


36. Dermatology Nurses Association



37. Division of Nursing, DHHS, HRSA


38. Emergency Nurses Association


39. George Washington University


40. Health Resources and Services Administration


41. Infusion Nurses Society


42. International Nurses Society on Addictions


43. International Society of Psychiatric-Mental Health Nurses


44. Kentucky Board of Nursing


45. National Association of Clinical Nurse Specialists


46. National Association of Neonatal Nurses


47. National Association of Nurse Practitioners in Women’s Health, Council on Accreditation


48. National Association of Pediatric Nurse Practitioners


49. National Association of School of Nurses


50. National Association of Orthopedic Nurses


51. National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Nursing Specialties


52. National Conference of Gerontological Nurse Practitioners


53. National Council of State Boards of Nursing


54. National League for Nursing


55. National League for Nursing Accrediting Commission


56. National Organization of Nurse Practitioner Faculties


57. Nephrology Nursing Certification Commission


58. North American Nursing Diagnosis Association International


59. Nurses Organization of Veterans Affairs


60. Oncology Nursing Certification Corporation


61. Oncology Nursing Society


62. Pediatric Nursing Certification Board


63. Pennsylvania State Board of Nursing


64. Public Health Nursing Section of the American Public Health Association


65. Rehabilitation Nursing Certification Board


66. Society for Vascular Nursing


67. Texas Nurses Association


68. Texas State Board of Nursing


69. Utah State Board of Nursing


70. Women’s Health, Obstetric & Neonatal Nurses


71. Wound, Ostomy, & Continence Nurses Society


72. Wound, Ostomy, & Continence Nursing Certification

Mar 18, 2017 | Posted by in NURSING | Comments Off on The Politics of Advanced Practice Nursing
Premium Wordpress Themes by UFO Themes