Since the inception of the nurse practitioner (NP) role in the 1960s, NPs have struggled to define and advance the profession by gaining its acceptance at various legislative and regulatory levels. While NPs have had full practice authority in the state of Wyoming since 1983, the introduction of the emergency nurse practitioner (ENP) certification in 2017 set the stage for critical examination of the NP role within the state. Combined with the cumbersome language of the Consensus Model for APRN Regulation (APRN Consensus Work Group & the National Council for State Boards of Nursing APRN Advisory Committee, 2008) regarding inconsistent standards in NP education, the ENP certification created a state of confusion among health care leaders in Wyoming, including hospital credentialing committees, hospital executives, and nurse practitioners. Health care leaders within the state became aware of the family nurse practitioners' (FNPs) lack of formal training in emergency care and began to question the competency of FNPs working in emergency care settings. However, the leaders were skeptical of a new specialty certification for NPs that would address practice in the emergency departments (ED) and verify competency in emergency care. Throughout the state, the reflex action to the ENP certification was that of resistance.
FNPs working in EDs within Wyoming began to feel pressure from hospital administrators due to the perception that FNPs are not properly educated to work in emergency care settings. Some hospitals replaced emergency care NPs with physician assistants (PAs) and physicians, while many other hospitals in the state were too financially constrained to employ physicians alone or for the supervision of PAs. In response, NPs reached out to the state advanced practice nursing organization, the Wyoming Council for Advanced Practice Nurses, and hospital administrators sought the help of the Wyoming Hospital Association, culminating in the unplanned development of a large group of stakeholders with a coordinated determination.
As with any change process, it was important to engage the skeptics, make them feel understood, and develop a concerted effort to reshape their resistance. After holding listening sessions with the resistors, it was discovered that the resistance to acknowledge a new NP specialty certification was based on blind spots, or a lack of knowledge about the ENP role. Using cornerstone documents, such as those that set practice standards and scope of practice for the emergency nurse practitioner, NP stakeholders were educated about the ENP role. As leaders within the state began to understand and recognize the benefits of the ENP role, they asked to participate and help get the role acknowledged.
Getting a first follower, the state's hospital association, was crucial because they helped emphasize the importance of our efforts to their affiliates. Working with the Wyoming Hospital Association to address this critical problem, hospitals around the state started to see the benefit of emergency care education in addition to that of the FNP's formal education and in turn became supporters of the ENP role and requested that the state board of nursing acknowledge the role. While the Consensus Model for APRN Regulation (APRN Consensus Work Group & the National Council for State Boards of Nursing APRN Advisory Committee, 2008) indicates state boards of nursing cannot regulate practice at the specialty level, hospital credentialing committees were hesitant to hire ENPs without the role and scope of practice being formally acknowledged by the board of nursing. Specifically, hospital administrators were asking for the board of nursing's opinion about the ENP role and certification.
The Wyoming Council for Advanced Practice Nurses (WCAPN) petitioned the Wyoming Board of Nursing to provide an advisory opinion and the board of nursing stated, “Throughout the literature there is valid and substantial support for family nurse practitioners to obtain specialty education to provide emergency care. However, a definition of emergency care is not clearly stated within this literature. State boards of nursing and other regulatory organizations need an authoritative definition of emergency care to help regulate advanced practice registered nurse (APRN) scope of practice, define national professional standards, and ensure congruence among educational programs” (J. Burns, written communication, February 28, 2019). A concept analysis was performed to supply the board of nursing with a definition that could be used to operationalize the practice of emergency care for ENPs (Davis, Dowling, Fiebig, & Lewis, 2019). Using the definition, an advisory opinion was drafted by WCAPN and the Wyoming state American Academy of Emergency Nurse Practitioners (AAENP) representative and then submitted to the board of nursing for approval. The Wyoming Board of Nursing became a regulatory-level stakeholder in the evolution of the ENP role, releasing an advisory opinion to acknowledge the ENP specialty, as it is defined by the AAENP and posting the AAENP Practice Standards for the Emergency Nurse Practitioner Specialty on the board of nursing's website.
An effective change strategy is essential to the evolution of all professions. Identifying stakeholders and resistors is a critical first step to begin effective dialogue. While resistance is a normal reaction, when it appears, it is important to focus on listening and identification of the problem rather than on overcoming. Look for strength within the resistance by focusing conversations on finding a common purpose to facilitate understanding and build respect. As relationships are built and stakeholders are secured, begin to anchor your purpose, but remain flexible. This success story for ENPs in Wyoming should serve as a representative case for other states to begin the process of acknowledging the practice of ENPs.
–Wesley Daniel Davis, DNP, ENP-C,
FNP-C, AGACNP-BC, CEN
Assistant Professor and ENP Program
College of Nursing,
University of South Alabama,
Davis W. D., Dowling D., Fiebig W., Lewis C. (2019). Emergency care: Operationalizing the practice through a concept analysis. Journal of the American Academy of Nurse Practitioners. doi:10.1097/JXX.0000000000000229