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.