Abstract
In 2004, various organizations came together and developed a consensus on how to develop an acceptable way of accrediting nurses in the country. A model was developed to help valuate contribution of the nursing profession to the general healthcare system. The model was accepted in some states with implementation of legislation giving limited validity to the model the new model was different from the earlier attempts in that it was a more liberal version of accreditation criterion attempted before. However, legal barriers stand in the way of implementation of the consensus model. With time, the model is adapting to legal system in various states albeit with legal hitches.
Introduction
Advanced practice registered nurse (APRN) refers to a nurse with an advanced level of training and education to be able to handle issues in advanced nursing practice. APRN certification requires a wide range of requirements varying from education experience and the ability to make critical and well-informed judgments in advanced nursing (Phillips, 2008). This certification recognizes the achievement of a nurse in the profession. Between 2004 and 2008, a new set of APRN consensus model regulations was developed to set a new standard for nurses interested in gaining formally recognized professional status. This set of regulations was a consensus between groups and organizations dealing with advanced nursing. However, for the regulations to be acceptable as conventional standards and implemented within states, approval of its various aspects and clauses was necessary (NCSBN, 2006). Consequently, the new consensus had to make it through legal barriers, institutional bureaucracy, and politics. Every year, the implementation of the consensus has demonstrated progress. Currently, seventeen states are in the process of legally adopting the consensus and its regulations. Some of the states have already implemented the consensus clauses to a significant extent. Although the APRN certification has its own standards, accreditation techniques and education requirements, the legislations of various states must approve the consensus implementation.
The need to improve accessibility of advanced health care nursing was one of the main reasons for the formulation of this consensus. In addition, there was the need to recognize the nursing profession as a progressive career (Blancett & Flarey, 1996). This would be supportive to nursing practitioners who would be able to offer high quality advanced services to the population of the country. However, the main aim of the consensus was to ensure responsible and accountable nursing practices to protect the public from any possible malpractice. This constitutes the ethical aspect of nursing which is a major component of advanced healthcare nursing. Another aim of the consensus was to increase social awareness regarding the need for high quality advanced nursing for patients in critical conditions, which need skilled professional attention. The possession of the certification by a practicing nurse means that he or she is skilled enough to offer services of a quality that licensing alone cannot guarantee. In this essence, APRN licensing is within the practitioner’s discretion and its issuing depends on whether the particular nurse has met the threshold requirements. The accreditation also serves as evidence of experience and advanced skills in professional nursing (Hamric & Hanson, 2005).
Skilled nursing services prove to be economically advantageous to the patient. This is because the APRN certified nurses have attained a high capability to provide efficient health care, which is less costly. The certification has also enabled the states to pass laws allowing the APRN certified healthcare practitioners to perform some duties traditionally reserved for professional doctors.
In addition to healthcare quality and the cost of accessing quality healthcare, the need to supplement existing laws and regulations to protect the public was also fundamental in instigating the effort to develop the consensus. The existing regulations and legislative limits governing the nursing practice took care of only the education aspect of the nursing practice. In addition, the new APRN consensus regulations provide a means for regulating the nurses offering their services as advanced nursing healthcare practitioners. Traditionally, nursing has been viewed as an expensive service without any real curative value for the patient (McGee & Castledine, 2003). This view has prevented the accordance of the real valuation of the nursing services. Furthermore, the separate billing system employed by most of the healthcare institutions in the country promotes this discrimination. In this way, the perception regarding nursing is that of an additional service to the services of doctors and other medical practitioners. The APRN consensus legislation seeks to evaluate the nurses’ services and mark their contribution to the general population and the economy.
Problems Encountered During the Legislation Process
The major feature of the consensus that limits full legislation of the APRN regulations is the fact that states limit the extent of the regulations usage. In this regard, the legislatures of diferrent states allow limited functionality of the APRN consensus regulations such that the adoption process is a slow. Moreover, the adoption of the regulations and practice standards is not uniform throughout the states. While some of the states have adopted most of the regulations and practice standards, others have not recognized the validity or importance of the accreditation and licensing of the APRN healthcare practitioners. In addition, the consensus did not reach the number of organizations required to formulate the regulations. The low turnout of 23 organizations out of the 50 that were invited led to a dismal reception of the consensus regulations by some states. The progress of implementation has become difficult to monitor due to the non-uniformity of the effort to embrace the new standards. However later in the program, more participants joined to cement the credibility of the APRN certification. In most of the states, the state government wishes to control the limits of practice by medical practitioners. Nurses are also subject to this traditional. Most legislative bodies within the states find it difficult to sanction the APRN certification as a valid high standard for nurses in all nursing field. This is due to the liberal nature of the regulations and the requirements of the APRN consensus regulations. The fact the APRN consensus regulations do not license the qualified nurses to a single and specific field make it difficult for legislators to find a platform on which to allow the regulations to be adopted as parameters for assessing nursing care specialists.
The majority of the states were reluctant to pass the legislation of the APRN consensus regulations due to the nature of nursing education. Each state had specific criteria of evaluating a nurse’s qualification. This method differed from the criterion used by the APRN certification board. The government thus finds it difficult to enact laws, which place some nurses in superior class of practice since they might not find a standard definition for the advanced nursing practitioner as proposed by the consensus. The upgrade of the services offered by APRN nursing care practitioners to include some services rendered by physicians has caused confusion in setting up a proper standard for the nurses while clearly defining a role different from that of a doctor (“Uniform Advanced Practice Registered Nurse Licensure,” 2002.) A criterion for paying the nurses is difficult to develop and since this is a part of the legislation procedure, it hampers the acceptability of the APRN consensus regulation as a standard.
The medical practitioners’ roles are ill defined by the law, and the level of education required to allow a nurse to engage in offering certain services varies from state to state. A nurse trained in a nationally recognized school is certified as a competent expert in offering a certain range of services to citizens of the United States. However, the nurse’s practice is restricted in one state and prohibited in another. Two nurses with the same level of education may qualify for accreditation by the APRN certification board, but the legal requirements in one of the states in which one of them practices may not consider her eligible for certification as an advanced nursing practitioner. Politics considerably influence the modification of these legal requirements. This creates a dilemma for the legislature and the APRN consensus group concerning the nurse licensing.
Level of Progress and Anticipated Achievements
All of the states that have adopted the new consensus regulations have reported some degree of positive progress at different rates. Some of the states reported the APRN nurses improved the quality of prescriptions due to the practitioners’ experience and academic knowledge. Treatments such as pain management, which were regulated by statutory laws, have been put under the full authority of the APRN healthcare practitioners. This has enabled the management of the ailments and clinical conditions more dynamic and adaptive to specific conditions consequently bettering the treatment for patients. Moreover, the presence of trustable medical practitioners to decide on the handling of the substances has facilitated the elimination of restrictions on some of the controlled pharmaceutical substances used for therapeutic purposes (Phillips, 2008).
The intention by some states to institute new criteria for the reimbursement of APRN healthcare experts boosts the additional step in the APRN adoption as the accepted professional standard. Although there is no actual step in any of the states to change the reimbursement criteria for the nurses, some states have indicated that there will be a new methodology of reimbursement for the APRNs. However, this step is not a formal clause in the laws passed by the legislature. All the states intend to adopt the proposed standards although the extent of the adoption is yet to be determined (Nursing, 2011).
The proposed changes to the nursing profession have their demerits too. These emerge from the re-organization required for the legislation of laws that do not contradict at any one point. Since consensus regulations are a national standard with no variations, they require a uniform law to function properly in all states. This is because the states have different laws already governing the nursing profession. The APRN regulations are obviously easier to manipulate than the state laws. In this regard, the consensus requires an extensive revision to be operational in all the states (Harris, 1997). The new regulations have caused confusion in the nursing profession. Professionals’ ranking could become difficult since it is not compulsory for all nurses in a state to obtain an APRN license. Superiority in terms of the professional authority to deal with certain issues could become a dispute between highly trained nurses without the ARPN licensing and the licensed ones. Furthermore, the proposed bills create an imbalance in the provision of healthcare in the concerned states. Some of the states could develop a high standard of advanced nursing practice while others lag behind by a large margin.
The developers of the APRN standards and regulations are optimistic about the full implementation of the regulations and their adoption as a policy in the health sector by 2015 (Phillips, 2008). Their basis is on the current progress made in the legislation of the regulations in various states. Statistical reports indicate a positive response in the health sector meaning that the policy adoption may grow faster. Studies on the regulations’ performance illustrate that nurses’ classification and the valuation of their services increase their work efficiency. Assigning nurses a more involving responsibility has also empowered them in the execution of their duties (Leatt & Mapa, 2003).
Although the implementation of the regulations seems to be on the right track, the structure of administration in the country remains a barrier to the implementation of the regulations and standards. Just as any other national policies that are adopted differently across the country, the APRN regulations may settle with varying levels of legislation owing to the rigid form of some state governments. However, the APRN regulations on advanced nursing practice will have a lasting overall impact on the National Health Service quality (Marx, 2010).
Comparison with the Canadian system
In comparison with the Canadian system, the US healthcare system has a great deal of disharmony. The Canadian system has a harmonized training and licensing criteria, which has the specialist level, advanced nursing practitioner, and the basic nursing practice. At each level, the adoption of various variations of the profession occurs (Robinson, 2007). These could separate into educational fields, pediatric care, nurse associates, and other distinct fields. To acquire the status of a professional nurse in Canada, one has to attain a certain level of education experience or other forms of credits to obtain the license to practice at the certain relevant level. Consequently, the Canadians, even with the less advanced healthcare system, surpass the national nursing organization in the United States. The Canadian system uses the nursing schools association to accredit their nurses’ education level. The development of the Canadian accreditation system occurred in a similar way as the APRN consensus regulations. Accreditation started as a voluntary exercise and later included members from other professions. With time, the accrediting body assumed the major role in accrediting nurses and the members from other professions (Stanley, 2005). However, the Canadian system differs with the consensus initiative in the United States since the accrediting body is not limited to the nursing profession only. The criteria of establishment of the successful body is however similar.
If the APRN formulators revise their regulations and criteria of accreditation to suit the purpose of every state, it could then be more acceptable to the legislature of various states without any complications. If the modification of the regulations were in alignment with the education regulations of each individual state and the rudimentary accreditation system that exists in the state in question, it would be easier to implement the resolutions of the consensus. This would mean that the consensus group would have to revise the set regulations to develop a version for every state. Although this could consume more time and increase costs, it is the only way to ensure that all the states adapt to the APRN regulations within a reasonable length of time (Zaccagnini & White, 2011). It is more difficult to try to streamline the state laws that are already in place to conform to the new proposed regulations due to political technicalities.
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