1. Difference between NPs and PAs2. Barriers to APNs

The Origin of NPs and PAs Gaps in the distribution of physicians and

services in the rural and inner city . The cost effectiveness of these two roles,

especially when the health care cost is rising.

The patients’ high satisfaction level with NPs and PAs

In 2006, NPs and PAs have accounted for around one sixth of medical workforce in United States.

NPs vs PAs: Scope of PracticeThe supervisory physician is responsible for the PA at all times and must be available for consultation

A nurse practitioner works either independently or as part of a health care team

NPs vs PAs: Education All Pas and NPs are now graduates of formal,

accredited education programs. Most are at the graduate level, providing a master’s degree as a standard of education for both NPs and PAs.

The education of PAs students is disease centered, while for NPs students, it also emphasizes psychological and social care.

The NP curriculum follows nursing models of practice and emphasizes health assessment, diagnosis, and treatment, as well as health care maintenance and disease prevention.

NPs vs PAs: Abilities and Limitations 12 states nurse practitioners have no

collaboration requirement, 4 states require physician involvement but no written documentation.

11 states and D.C allow for nurse practitioners for independent prescriptive authority

PAs now are licensed in 44 states, but they have to work under the authority of a physician.

Comparison of NPs and PAs (Table from Curren, 2007)

Characteristics Nurse Practitioner Physician Assistant

Average Age 46.3 years 41.5 years

Gender Male (4.1%) Female (95.9%)

Male (46.2%) Female(53.8%)

Average Years in Practice 9.0 9.5

Number Employed 115,000 50,000

Background All are RNs RN, EMT, Medic, RT, PT

Number of US Schools 337 132

Curriculum Focus Health assessment, diagnosis, and treatment

Primary care, allopathic,osteopathic

Length of Education 12-43 months; mean = 21.5

12-39 months; mean = 25.5

Master’s Degree 72.4% 25.0%

Number of Graduates 102,829 52,716

Average Salary $73,620 $69,410

Certification Requirements

NCC, AANP, ANCC, NCBPNP

PANCE

Practice Autonomy Autonomous in most states

Physician supervisionrequired in most states

Primary Care Practitioners

85% 50%

The barriers to APNs: Public PolicyThe ability to be credentialed by health care

organizations is very important for APNs to have their own patients, but this credentialing is very difficult in managed care organizations (MCOs)

In many states of United States, physician involvement is required for APN prescription authority.

The barriers to APNs: Role ChangeConflict arose when APNs found that the

practice setting did not allow them to practice in a holistic manner that was consistent with the nursing role. Teaching and counseling is an important part

of the APN role and couldn’t be ignored APNs are not physician substitutes, they

should offer added difference

ConclusionCompared with PAs, NPs have more privileges

No need to work under the authority of a physicianPrescription Authority

There are still barriers to APNsLimitations on the credentialing and prescriptionSometimes hard to be consistent with the nursing role.

We should be ready to embrace the challenges Strong demand for APNs because of cost effectiveness

and high satisfaction levelThe constraints to the practice of APNs are gradually

removed by legislation.

Why Washington State Needs Change

What is an Advance Practice Nurse?Advanced Practice Registered Nurse (APRN)

is an umbrella term for four groups of advanced practice nurses. Clinical Nurse Specialists Nurse Anesthetists Nurse MidwivesNurse PractitionersAll with a Different Focus and Scope of

Practice

What is a CNS?The first APRN

unique body of knowledge and competencies based on education at the graduate level (Mick and Ackerman, 2002)

Advance Practice Nursing Started with Peplau in the 1940’s (Peplau, 1965).

Differentiated from the expertise of other APRN

In 1965 the ANA declare that the that the Title of CNS should only be used by Nurses with a Master’s Degree and higher (ANA, 1965)

CNS Scope and ExpertiseThree Main Spheres of Influence

Patient/client sphere;Nurse/Nursing Sphere; andSystem/Organizational Sphere (NACNS, 2004).Specialized Knowledge, Experience, and

Education in a specific field, setting, or population.

Prescriptitory rights in field of specialization.

Varies by State

CNS FNP

Specific Patient Population

Specific ScopeAcute CareSystem wide Focus

ResearcherStaff EducatorFocus on Quality of

Care Issues

Individual PatientGeneral ScopePrimary CareIndividual Focus

Focus on direct patient care

Prescriptitory authorityReferral and consultation to other HCPDurable Medical EquipmentDiagnostic TestPharmacologic when appropriate to Specialty

Protection of TitleNot a protected title in Washington StateWashington Department of Personnel in July,

2007 created a “Class Specification”Specific “Distinguishing Characteristics”Specific description of “Typical Work”Specific “Knowledge and Abilities”BUT, legal requirements are only a RNAND, a Master’s Degree is only “Desirable”

and “Equivalent education / experience” can substitute

Why Should the Title Be Protected with Educational RequirementsImprove Patient Care

Increased Education Increases Nursing Care (AACN, 2008)

Provide Incentives for Educational GrowthSome States are Offering a $20,000 signing

bonus for CNSEstablish Parity with other Professions

PA, Current Pharmacist, Current PTsEstablish Parity with other States

Where is the Title Protected

How is it ProtectedLegislative actions

LawsNursing Practice actsState Nursing Board Changes

CertificationRegistrationSome State second LicensingSpecific Requirements

Second License ConcernsThere are over 40 CNS specialty areas of

practiceOnly 9 CNS specialty exams exist (NACNS,

2003)-Adult -Acute and Critical Care-Gerontology -Pediatrics-Adult Mental Health -Pediatric Mental Health-Home Health -Diabetes Management -Public/Community Health

If a specialty exam does not exist may have to take a general med/surg exam.

A “New Way”ANCC New Core CNS Clinical Nurse

Specialist Exam (currently under Development)

“Critical Portfolio” Examine Experience and EducationUse of other exams Oncology Certified Nurse Certified Nurse Operating Room (CNOR)RN First Assist (RNFA)Certified Chemotherapy Nurse Dermatology Nurse Certified (DNC)

SummaryCNS Represent a unique role

Different from NPDifferent from RN

Title needs legal and regulatory protection

Washington State should implement laws and regulations to protect and recognize the CNS role.

References Curren, J. (2007). Professional Issue. Nurse Practitioners and Physician Assistants: Do You

Know the Difference? MEDSURG Nursing, 2007 Dec; 16 (6): 404-7. Plager, KA.; Conger, MM. (2007). Advanced Practice Nursing. Internet Journal of Advanced

Nursing Practice, 2007; 9 (1). McCabe, S.; Burman, ME. (2006). A Tale of Two APNs: Addressing Blurred Practice Boundaries

in APN Practice. Perspectives in Psychiatric Care, 2006 Feb; 42 (1): 3-12. Mick, D. J. and Ackermn, M. H. (2002). Deconstructing the myth of the advanced practice

blended role: Support for role divergence. Heart and Lung, 31(6), 393-398. American Nurses Association. (1965). Educational Preparation for Nurse Practitiners and

Assistants to Nurses: A Position Paper. American Nurses Association. 1965. New York. Peplau, H. (1965) Specialization in Professional Nursing. Nursing Science, 3, 268-287. NACNS. (2004). Statement on Clinical Nurse Specialist Practice and Education: Second Edition.

National Association of Clinical Nurse Specialist. 2004 Harrisburg, PA. NACNS. 2003 Testimony to the Federal Trade Commission on Regulatory Credentialing

Barriers For Clinical Nurse Specialists (CNS). National Association of Clinical Nurse Specialist. 2004 Harrisburg, PA. http://www.nacns.org/TESTIMONY.pdf. Accessed 7/26/2008.

AACN. (2008)Fact Sheet:The Impact of Education on Nursing Practice American Association of Colleges of Nursing http://www.aacn.nche.edu/Media/pdf/EdImpact.pdf . Updated 6/2/08. Accessed 7/26/08