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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000415950.08815.13
AJN Reports

In the Final Stretch: Standardizing APRN Practice

Nelson, Roxanne BSN, RN

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Variations among state regulations still present hurdles.

The number of advanced practice nurses (APRNs) has expanded significantly over the past few decades, and more and more, these nurses are performing duties that were once reserved for physicians. Although APRNs play a vital role in health care delivery, their scope of practice varies widely from state to state. All four groups considered to be APRNs—NPs, clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs)—are regulated under state licensing and certification requirements that remain inconsistent nationwide.

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The 2008 report Consensus Model for APRN Regulation from the APRN Joint Dialogue Group, a collaborative effort of the APRN Consensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRN Advisory Committee, with input from numerous nationwide nursing specialty organizations, aimed to establish a multistate licensure compact and national standards for the uniform regulation of APRNs. As the NCSBN states in its explanatory notes on the compact (, “As long as regulatory requirements differ from state to state, each state border represents an obstacle to portability,” which creates difficulties for practitioners and patients alike. Adoption of the model would streamline regulatory requirements not only for licensure, but also for accreditation, certification, and education in each APRN group.

Although the model has been endorsed by almost all APRN organizations in the United States, nationwide implementation hasn't been achieved. “I would say that if this were the marathon, we're at mile 17,” said Maureen Cahill, MSN, RN, an associate in outreach services at the NCSBN's Campaign for Consensus. “Far enough along that you're not going to think about stopping. There's just too much effort in there to quit.” But those last miles can be the hardest, she added.

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Currently, every state independently determines the legal scope of APRN practice; APRNs' roles, titles, and criteria for entry into advanced practice; and which certification examinations are accepted. These inconsistencies among jurisdictions create confusion for other professionals, the general public, and even nurses. “Sometimes states have been able to modify their rules, but most have to go back and alter their nurse practice act,” Cahill explained. And that requires legislative action.

For example, Alabama and Florida don't authorize any APRN to prescribe controlled substances. And in other states, permission to prescribe such agents is limited to certain APRNs. In 22 states, NPs can diagnose and treat patients independently without physician involvement. Conversely, 24 states require some sort of formal relationship with a physician that is documented in writing. (Most of these data come from the NCSBN's Scope of Practice FAQs for Consumers, which can be found at

The ability of CRNAs to work without physician supervision in hospitals and outpatient clinics is regulated by both state and federal law. Federal Medicare reimbursement requirements can be particularly complex for CRNAs because states must formally opt out of physician-supervision requirements; only 16 states have laws that permit CRNAs to work without physician supervision and have also opted out of the federal supervision requirements.

CNMs can work independently in 18 states, whereas others have some type of physician-collaboration requirement. Prescriptive authority is given to CNMs in all states, but 11 require some degree of physician involvement.

Another hurdle to the implementation of the consensus model is that state boards of nursing may lack the power to move the legislative agenda forward. “We really depend on nurse action coalitions and state nursing societies,” said Cahill. “These grassroots groups are the ones who help get the nurse practice act open [enabled for legislative changes] and in alignment with consensus.”

Varying degrees of physician resistance to the expansion of APRNs' scope of practice may also impede progress in states with more restrictive regulations. But as the Patient Protection and Affordable Care Act provides incentives to all states to consider expanding their workforce, explained Cahill, “reducing the barriers to APRN practice becomes a relatively fast way to get that expansion accomplished.”

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In 2006 the NCSBN released a draft of Vision Paper: The Future Regulation of Advanced Practice Nursing to members of the nursing community. At that time, it was proposed that APRN licensure include the CRNA, the CNM, and the NP—but not the CNS. The reasoning at the time was that an APRN practices outside the scope of RN practice, but many CNSs don't. That position has since been reversed, and the National Association of Clinical Nurse Specialists (NACNS) recently became a signatory to the consensus model document. “We fully support the model, and it makes sense,” said NACNS president Rachel Moody, MS, RN, CNS. “We have been involved in the process and are moving forward with it.”

But concerns linger, particularly about the grandfathering of the CNS role—the definition of which has been particularly inconsistent from state to state—under the APRN umbrella. Because the care CNSs provide differs depending on the setting, as well as other factors, many states lack a unified description of the CNS scope of practice. “We want to make sure that there is across-state recognition of grandfathering,” said Moody. “For example, I live in Indiana and I don't need to have an advanced practice license. At this time in my state, the CNS title is protected and certification isn't required.” On the other hand, she added, other states interpret grandfathering differently. “If I moved to a different state, I might not be able to work as a CNS.”

Another concern is that examinations pertaining to each of the six “population foci” stipulated in the model haven't been developed for the CNS. For example, explained Moody, “family/individual across the lifespan” is a population focus in the model, but there isn't yet a CNS certification in that category. “That's something we are working on right now,” she said. Alignment of the CNS educational curricula with the model, too, will be required to attain more uniformity. “This is all going to take some time,” said Moody.

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Whether all APRN groups can simultaneously cross the implementation finish line on time is an open question. Not all APRN groups are operating on the same timeline. The NACNS noted in a recent statement ( that it would prefer to see “diligent, sequential implementation of aspects of this model,” even if that means a delay in implementation.

But Cahill remains optimistic. “I believe there's a tipping point, a ‘magical mile’ in this marathon.” However, she added, once that tipping point is reached, the states that are behind may need to race harder to catch up. About 65% of the major elements have been adopted by states and jurisdictions, Cahill estimates. “It's all uphill now,” she said, “but we're hoping it will move more quickly toward the end.”—Roxanne Nelson BSN, RN

© 2012 Lippincott Williams & Wilkins, Inc.


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