1. APRN Consensus Model: Patti Zuzelo, EdD, MSN, RN, ACNS-BC, ANP-BC, CRNP Immediate Past-President, National Association of Clinical Nurse Specialists Professor of Nursing DNP Program Director & CNS Track Coordinator, La Salle University Implications for advanced practice registered nurses: education, practice, & specialization

2. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education  APRN: NAs, CNMs, NPs, CNSs  No uniform model of APRN regulation across states.  Model only addresses APRNs. Not to say that advanced, graduate nursing roles are unimportant but are not practice roles i.e. basic licensure is fine. Brainstorming activities  Model created by Advanced Practice Nursing Consensus Work Group and the National Council of State Boards of Nursing (NCSBN).

3. Roles + Population = APRN  APRNs must be educated in at least one of six population foci: family/individual across the lifespan adult-gerontology Pediatrics Neonatal women’s health/gender-related psych/mental health

4. Other requirements  APRN programs must be accredited  APRN education: broad-based and the “3 Ps” through separate courses  Appropriate clinical experiences given the population and role

5. Certification exams  Once appropriate education completed, candidates will sit for a certification exam to assess: National competencies of APRN core Role At least one population focus area of practice for regulatory purposes.  Certification programs will be accredited by a national certification accrediting body  APRN certification programs will require a continued competency mechanism

6. Who accredits the certification programs?  Two options for national accreditation: 1. American Board of Nursing Specialties 2. National Commission for Certifying Agencies

7. What does the nurse “get” after completing this process?  Licensure as independent practitioners for practice at the level of one of the four APRN roles within at least one of the six identified population foci.  Education, certification, and licensure must be congruent.  APRNs may specialize but they CANNOT be licensed solely within a specialty area.

8. Specialties can provide depth in one’s practice within the established population foci.

9. Specialization  Education for a particular specialty can occur at the same time as the APRN education required for licensure OR through post-graduate education.  Competency in specialty will be assessed by the appropriate professional organizations; NOT by boards of nursing.

10. LACE  Need transparency throughout this continued process & effective communication between the various aspects of licensure, accreditation, certification and education bodies i.e. LACE.

11. Definition of an APRN per the APRN Consensus Model 1. Completed an accredited, graduate-level education program in one of the 4 recognized roles. 2. Passed a national certification exam measuring APRN role and population-focused competencies, and maintains continued competence (i.e. recertification). 3. Acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients & a component of indirect care. SIGNIFICANT COMPONENT of education and practice focuses on direct care.

12. 4. Practice builds on RN competencies. Greater depth, breadth, synthesis, complexity, and role autonomy. 5. Educationally prepared to assume responsibility & accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems—including the use and prescription of pharmacologic and non- pharmacologic interventions. 6. Has sufficient depth of practice AND 7. Has obtained a license to practice as an APRN in one of the four APRN roles.

13. CNP  Direct primary and acute care across settings.  Prepared to practice as primary care certified nurse practitioners AND acute care CNPs.  Separate national consensus-based competencies and separate certification processes.

14. CNS  Integrate care across the continuum and through 3 spheres of influence: patient, nurse, system.  Primary goal: continuous improvement of patient outcomes and nursing care.  Key elements: create environments through mentoring and system changes that empower nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical decision-making, and respond to diversity.

15. Titling  APRN is the licensing title.  Legally protected title.  Licensure and practice scope are based on graduate education in one of the 4 roles and in a defined population.  Individual must legally represent themselves as an APRN AND BY THE ROLE.

17. Points to consider  CNP prepared with acute care CNP competencies and/or the primary care CNP competencies.  This delineation applies only to the pediatric and adult-gero CNP population foci.  Scope of practice is based on patient care needs— not setting specific.  If programs prepare graduates across both sets of roles, the graduate must be prepared with the consensus based competencies for both roles and must successfully obtain certification in both the acute and primary care CNP roles.  Certification must match educational preparation.

18. Population focus  Adult-gero: young adult to older adult, including frail elders.  APRNs educated and certified in the adult-gero population are educated and certified across both areas of practice.  Titled Adult-Gerontology CNP or CNS

19. Requirement  All APRNs in any of the four roles providing care to the adult population must be prepared to meet the growing needs of the older adult population.  Education program should include didactic and clinical education experiences necessary to prepare APRNs with these enhanced skills & knowledge.

20. Broad-based APRN Education  APRN core: Advanced physiology/pathophysiology, including general principles that apply across the lifespan. Advanced health assessment, includes assessment of all human systems, advanced assessment techniques, concepts and approaches Advanced pharmacology, includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents.

21. Accreditation process  All APRN programs must undergo a pre- approval, pre-accreditation, or accreditation process prior to admitting students.  Rationale:  Ensure that graduating students will be able to meet the education criteria necessary for national certification and population-focus  Ensure that programs will meet all educational standards prior to starting the program.

22. APRN Specialties  Preparation in a specialty area is optional. If included, must build on the APRN role/population-focused competencies.  Specialty practice may focus on specific patient populations beyond those identified or health care needs i.e. oncology, palliative care, substance abuse, or nephrology.  Definition of APRN specialty built upon the ANA (2004) Criteria for Recognition as a Nursing Specialty.

23.  Caveats:  Specialty preparation cannot replace educational preparation in the role OR one of the six population foci.  Specialty preparation cannot expand one’s scope of practice beyond the role or population focus.  Specialty addresses a subset of the population- focus.  Specialty title may not be used in lieu of the licensing title, which includes the role or role/population.  Specialty is developed, recognized, and monitored by the profession.

24. Summary Education programs preparing individuals with this additional knowledge in a specialty, if used for entry into advanced practice registered nursing and for regulatory purposes, MUST also prepare individuals in one of the four nationally recognized APRN roles AND in one of the 6 population foci.

25. Need for new APRN roles  If new roles emerge or new population- focus is necessary, this needs discussed and vetted through the national LACE structure.

27. Foundational requirements for licensure  Select requirements: Boards of nursing will: Require successful completion of a national certification examination that assesses APRN core, role and population competencies for APRN licensure. License APRNs as independent practitioners with no regulatory requirements for collaboration, direction or supervision Allow for mutual recognition of advanced practice registered nursing through the APRN Compact Institute a grandfathering clause that will exempt those APRNs already practicing in the state from new eligibility requirements.

28. Timeline  Incremental implementation  Target date for full implementation of the Regulatory Model and all embedded recommendations is the year 2015.

29. Challenges and concerns  Nurse practitioner prepared in primary care adult-gero program.  Seeks employment working with a cardiology group that requires management of hospital case load as well as office case load.  Acute care NP certification versus Adult- Gerontology primary care certification?

30. CNS  Adult-gerontology CNS prepared in adult health program.  Role must include health promotion, primary care, disease prevention.  Employed in acute care setting working with patients requiring telemetry in a medical-surgical facility.

31. Geriatric specialty practice  Must be educated within parameters of specific populations, including adult + gerontology.  Implications for geriatric NPs and geriatric CNSs?

32. AANA endorsement  Notes support.  Makes clear that CNAs prepared as such remain APRNs despite their daily involvement in education and administration.

34. References APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee (2008). Consensus model for APRN regulation: Licensure, Accreditation, Certification & Education. Retrieved January 28, 2009 from, http://www.nacns.org/LinkClick.aspx?fileticket=4sNIeHon3DA%3 d&tabid=78 http://www.nacns.org/LinkClick.aspx?fileticket=4sNIeHon3DA%3 d&tabid=78 NCSBN. (2008). APRN Model Act/Rules and Regulations. Retrieved January 28, 2009 from, https://www.ncsbn.org/APRN_leg_language_approved_8_08.pdf