Policies & Practice Standards • State Nurse Practice Act NSG6006 Study Guide 5000 (Roles) • _History and Developmental Aspects of Advanced Practice Nursing • Definition of advanced practice nurse (APN) - A nurse who has completed an accredited graduate-level education program preparing her or him for the role of certified nurse practitioner, certified registered nurse anesthetist, certified nurse-midwife, or clinical nurse specialist; has passed a national certification examination that measures the APRN role and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN involves advanced nursing knowledge and skills; it is not a medical practice, although APNs perform expanded medical therapeutics in many roles • History of APN movement History and evolution of nursing science Knowledge development APN Roles CNSs have a strong and tumultuous history. Over the past 20 years, the departure from direct patient care as being a main focus to working predominantly in the nursing education and systems improvement domains has created confusion within nursing and the public because nonCNSs (e.g., nurse educators, quality improvement managers) function in the same capacity. However, CNSs are uniquely educated to provide advanced practice and specialist expertise when working directly with complex and vulnerable patients, educating and supporting interdisciplinary staff, and facilitating change and innovation in health care systems that those in other roles in health care cannot. As health care reform continues to gain momentum to improve the health care system, there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can develop new roles to meet the needs of patients and health care systems. For example, in nursemanaged clinics, perhaps NPs could deliver the primary care to patients in the management of hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a referral could be placed to the cardiovascular CNS for specialized pharmacologic and nonpharmacological treatment. Also, the cardiovascular CNS could integrate the latest evidence to create educational materials for patients and other health care professionals. Perhaps a CNM who is caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech position could ask the perinatal CNS to commonage the patient by following the patient and fetus or neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal CNS could establish interagency processes to facilitate care delivery across practice settings to provide seamless transitions of care. The possibilities are endless if CNSs understand their role, improve understanding of the importance of this role in advanced practice nursing, and maximize the driving forces and minimize the restraining forces in the health care system. Primary care is the foundation of the evolving U.S. health care system. If access to primary care for all is the goal, while containing costs and focusing on quality outcomes, then NPs will be crucial to achieving these aims. In our current system, there just aren't enough PCPs to meet the need and, with an additional estimated 32 million more people who will be covered and need access to full primary care, based on the PPACA, we will need additional providers more than ever. Physicians are not choosing primary care practice for complex reasons. On the other hand, most NPs choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these programs specifically to provide primary care. Two areas in particular must be addressed before NPs will be able to contribute fully to primary care delivery nationwide: 1.There must be changes in the outdated state scope of practice laws and regulations of nurse practitioners. This is because the variation in state regulations on scope of practice and prescribing authority has been a major barrier to using NPs fully and providing increased access to quality, cost-efficient primary care. 2.There must be substantive changes in health professional education to foster true 2 collaboration and teamwork among physicians, NPs, and other health care disciplines in general to obtain the full benefit of diverse competencies inherent in a team. 3 If both of these are addressed, meeting U.S. primary care needs could be significantly affected in a positive way. Today's NP students and graduates must accept the professional responsibility for being active in the governance of delivery systems and informing and changing policy. There is too much at stake to leave this to a few, or to someone else. The health of the United States population depends on new models of care, on all health care providers practicing to the fullest extent of their education and training, and on strong teams who respect each other and partner with patients. NPs must support their efforts as they take an active role in developing stable health care policy and care delivery systems that allow for patient access to primary care services provided by NPs. The ACNP role provides an opportunity for NPs to have a significant impact on patient outcomes at a dynamic time in the history of health care delivery. As their role continues to evolve, and as health care systems respond to market forces and economic change, opportunities to develop the ACNP role further will arise. Future development of the ACNP role should be based on the evaluation of the need for the role, understanding the scope of the role, assessment of the practice or organization, and the service needs of the patient population. Ensuring that ACNPs practice to the full scope of (2011). Because the ACNP role continues to evolve, participation in national organizations to refine consensus regarding role components, program curriculum, marketing, and role evaluation is necessary. ACNP educators and clinicians must work together to ensure that the preparation and practice of ACNPs is safe, effective, and fully represented as the movement of doctoral APN education evolves. ACNPs must be strong activists in efforts to gain full recognition of their role within their proper scope of practice across acute care settings. In this evolving health care arena, ACNP practice is rapidly expanding and holds unlimited potential. Ongoing challenges include ensuring expansion of the ACNP with a focus on advanced practice nursing, rather than as a physician replacement model of care. Nurse-midwifery practice encompasses a full range of primary health care services for women, from adolescence beyond menopause. These services include the independent provision of primary care, gynecologic and family planning services, preconception care, pregnancy care, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. CNMs provide initial and ongoing comprehensive assessment, diagnosis, and treatment. They conduct physical examinations, prescribe medications, including controlled substances and contraceptive methods, admit, manage, and discharge patients from birth centers or hospitals, order and interpret laboratory and diagnostic tests, and order the use of medical devices. CNMs' care also includes health promotion, disease prevention, and individualized wellness education and counseling. CNMs must demonstrate that they meet the core competencies for basic midwifery practice of the ACNM (ACNM, 2008b) and must practice in accordance with the ACNM standards for the practice of midwifery (ACNM, 2011d). With constant changes in health care, CNMs may need to expand their knowledge and skills beyond that of basic CNM practice. Advanced CNM skills, such as level 1 ultrasound or acting as first assistant in surgery, may be incorporated into a CNM's practice as long as the CNM follows the recommendations for acquiring these skills by obtaining formal didactic and clinical training to ensure that the advanced skill is acquired and monitored to ensure patient safety. There have been many recent positive advances in nurse-midwifery and between nurse-midwifery and the broader health care system. The ACNM has been reaching out to professional nursing, midwifery, medical, policy, and public health colleagues nationally and internationally. There has been international recognition of the need for more midwives to reduce maternal and neonatal mortality. In the United States, the IOM report, the Future of Nursing, and passage of the PPACA has placed CNMs and other APRNs in a partnership role in redesigning the health care system for the future. From a midwifery perspective, we hope that this system will honor women and offer them support in realizing the power that comes with the choice of a woman-centered health care system. Nurse anesthesia, the earliest nursing specialty, was also the first nursing specialty to have standardized educational programs, a certification process, mandatory continuing education, and recertification. Nurse anesthetists have been involved in the development of anesthetic techniques along with physicians and engineers. CRNAs have been nursing leaders in obtaining third-party reimbursement for professional services and in coping with challenges such as the prospective payment system, managed care, and physician supervision. Nurse anesthetists provide surgical and