Today's emergency nurse practitioners (ENPs) bring several competencies to the table—those of knowledge through formal and ongoing education and skills through procedural training, in addition to a wealth of clinical experience. Emergency nurse practitioners across the country, however, have been dealing with practice issues, specifically about state law and regulations. Some ENPs have been informed by their respective hospitals employers or the physician groups that they have contracted with, that they are unable to practice in various emergency care settings (i.e., emergency departments [EDs]). This is, at times, based solely on the misinterpretation of ENPs' educational background and the core population they serve (e.g., family, acute care).
In the From the Editors column, the authors hope to clarify the Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation: Licensure, Accreditation, Certification and Education (American Nurses Credentialing Center [ANCC], 2008) statements about specialty practice. It is also our intent to utilize the framework of the American Nurses Association (ANA), Determining Scope of Practice for Advanced Practice Registered Nurses (APRNs), which delineates scope for APRNs, including ENPs. Finally, we conclude with a “call to action.”
CONSENSUS MODEL AND SPECIALTY PRACTICE
In 2008, the Consensus Model became the framework for nurse practitioner (NP) licensure, accreditation, certification, and education (ANCC, 2008). This model delineated the advanced practice nursing based on role (e.g., NP) and population-focused competencies (e.g., family/individual across the life span; ANCC, 2008). Specialty practice encompasses additional competencies that build upon areas of role and population. It is at the specialty level within the Consensus Model that concerns about scope of practice have surfaced (Hoyt & Proehl, 2015).
To date, the authors of the Consensus Model document, the ANA, the National Council of State Boards of Nursing (NCSBN), and the National Organization of Nurse Practitioner Faculties (NONPF), have offered much discussion about the role and scope of ENPs working in the specialty of emergency care. And, the American Academy of Emergency Nurse Practitioners (AAENP) has and will continue to adhere to the tenets set forth in the Consensus Model. Unfortunately, there are still several discussion items surrounding ENP specialty practice.
DETERMINING SCOPE OF PRACTICE
According to the ANA, the Determining Scope of Practice for Advanced Practice Registered Nurses (APRNs) was written to delineate scope for APRNs, which include ENPs. The following areas must be considered when determining practice: (1) scope and standards of practice, ethics, and certification; (2) state law and regulations; (3) institutional policies and procedures; and (4) self-determination, and professional liability and risk management concerns (ANA, 2018) (see Figure 1).
Scope and Standards of Practice, Ethics, and Certification
ANA states the scope and standards of practice are “the “who,” “what,” “where,” “when,” “why,” and “how” of nursing” for all nursing, including advanced practice nursing. The ANA also recognized specialty documents specific to practice based upon the organization established to develop those statements (scope and standards). The ANA has recognized emergency nursing (RNs and APRNs) as a specialty practice since 2011 (Emergency Nurses Association [ENA], 2011). The scope and standards for ENPs were established in 2016 by both the ENA and the AAENP. Competencies for NPs in the ED had been established since 2008 and endorsed by the NONPF and other stakeholders. As per the ANA and the Consensus Model, these documents support the scope and standards of practice for the NP in the ED.
State Law and Regulations
The ANA has determined that the practice of the APRN is explained by each state's nurse practice act and governed by the specific state boards of nursing (ANA, 2018). Each state may have its own additional documents or provisions. Specific acts in a state by APRNs may be provided in the form of opinion by the state board of nursing. This is where the area of practice becomes blurred. For example, many states are responding to the individual ENP, hospital system, or physician group and even developing position papers without acknowledging the work of the specialty organizations as prescribed by the Consensus Model and the ANA. Even states that don't adhere to the Consensus Model still have direct responsibility to acknowledge the specialty organizations' science behind their practice. The ENA and the AAENP (specialty organizations responsible for the specialty practice) have valid and reliable scientific evidence of scope and standards of practice, competencies, guidelines for academic and fellowship programs, and certification examinations. Thus, some state boards have offered varying statements that have not recognized the extensive work of the specialty professional organizations of emergency care and are not consistent with the Consensus Model. Opinion or position statements may have little authority but yield great influence on hospital institutions and physician groups when attempting to hire–fire and credential ENPs. The institutional policy and procedure then become tainted.
Institutional Policies and Procedures
Here are a few examples of written statements by state boards of nursing that leave ENP experts perplexed:
Nurse practitioners in the ED must be certified in the population of acute care. However, the Centers for Disease and Control and Prevention (CDC) clearly state than more than 40% of the more than 141 million patients seen in the ED are women and children and only 3%–5% are critical care patients. Therefore, an acute care nurse practitioner by education and certification does not possess the scope of practice to see the bulk of this population (CDC, 2014).
Family nurse practitioners (FNPs) cannot work in the ED because they have no acute care training. Although not trained in acute care, the FNP is trained to provide resuscitative care and primary care in the ED. Family nurse practitioners are certified to see patients across the life span according to the Consensus Model (ANCC, 2008). This knowledge, these skills, and many abilities were identified over a decade ago in the Competencies for NPs in Emergency Care (ENA, 2008). They have also been documented in the academic curricula of ENP programs for several decades and most recently were revalidated in the ENP practice analysis, which was the basis for ENP certification examination (ENP-C).
The specialty educated and certified ENP cannot work in the ED because this individual does not have acute care training. In a comparison of the acute care competencies (NONPF, 2004) with the competencies for NPs in emergency care (ENA, 2008), the evidence is beyond refute.
The ENA and the AAENP concur that providers in the ED be educated in the specialty of emergency care. That is the recommendation of the both specialty groups—and these groups are the experts. The need for emergency care, established practice, formal and informal education, professional organizations, scope and standards, competencies and now the ENP certification are now the foundation for the ENP specialty. These cornerstones have been established to ensure that ENPs will provide high-quality, safe care for patients seen in all areas of emergency care.
Self-determination is another component of the ANA model that support the practice of an APRN in a specialty. Emergency nurse practitioners in the ED should be aware of their state nurse practice, as well as ENA and AAENP position statements. ENPs should also be prepared to articulate their scope of practice when working in the ED by disclosing education, both formal and continuing education, in the specialty practice based on the competencies for NPs in the ED.
Professional Liability and Risk Management Concerns
The final component to consider in context to APRN regulation is professional liability and risk management. Professional liability is the state of an ENP being legally responsible, accountable, and answerable for actions undertaken; risk management is the forecasting and evaluation of risks together with the identification of procedures to avoid or minimize the impact of liability. These issues become an even greater concern for ENP employers who read statements from state boards of nursing and are then wary about employing ENPs.
A CALL TO ACTION!
The issue regarding scope of practice is due in part to state boards of nursing composing these opinion statements to further clarify ENP scope of practice without the acknowledgement of the ANA document (ANA, 2018) or the adherence to the specialty component as outlined in the original Consensus Model document (ANCC, 2008). Furthermore, specialty organizations such as ENA and AAENP are not routinely queried by ENP employers with regard to their scopes, standards, certification, and competency information, which would help clarify this ongoing issue. As hospital credentialing committees and/or group practices review each state's opinion statements, in light of rendering a decision about the hiring of an ENP, time and time again, it has been noted by ENP experts that these groups were misinformed. Furthermore, institutions and group practices may have quality improvement and risk management concerns. For example, if the parties providing the information are not equipped to fully answer the queries, these groups will ultimately “err on the side of safety.” In other words, the ENP is not hired for the position. The issue appears to reside with state boards of nursing, which are remiss in acknowledging the ENP's specialty and body of science, which would have provided clear evidence of that ENP's qualifications. That evidence includes the distinctive knowledge, skills, and abilities of the ENP educated as an FNP with an emergency care specialty.
AAENP is working diligently with the NCSBN, the NONPF, the American Association of Colleges of Nursing, and most specifically the state boards of nursing to educate these nursing organizations. The AAENP continues to articulate our ENP competencies so as to clarify our position. The Consensus Model was not created to assist ENPs in losing their current positions of employment. The model was meant to support, promote, and provide clarification for ENPs.
Emergency care is a unique specialty. Emergency nurse practitioner have complied with the Consensus Model. It is incumbent upon us to continue to inform the various state boards of nursing about our ENP scope and standards, ENP competencies, and ENP certification. It is also imperative to protect and defend all ENPs who have and continue to work in emergency care. We must safeguard our disenfranchisement by those who are uninformed and/or those who have misinterpreted our scope of practice.
Please contact your AAENP regional or state representative for additional information. If you have a story to share, we'd love to hear from you. We will continue to be a united voice!
—K. Sue Hoyt, PhD, RN, FNP-BC, ENP-C,
CEN, FAEN, FAANP, FAAN
Advanced Emergency Nursing Journal
—Elda G. Ramirez, PhD, RN, FNP-BC,
ENP-C, FAEN, FAANP, FAAN
American Academy of Emergency Nurse
Professor of Clinical Nursing & Director of
Emergency/Trauma Nurse Practitioner
University of Texas Health Science Center