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Misalignment of specialty nurse practitioners and

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the Consensus Model

Grant R. Martsolf, PhD, MPH, RN, FAANa,b,*, Kristin H. Gigli, PhD, RN, CPNP-ACc, Benjamin R. Reynolds, MSPAS, PA-C, DFAAPAd, Michele McCorkle, MSN, RNe

aProfessor, University of Pittsburgh, School of Nursing, Acute and Tertiary Care Department, Pittsburgh, PA bAffiliated Adjunct Policy Researcher, RAND Corporation, RAND Health Care, Pittsburgh, PA

cPost-doctoral Scholar, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine,

Pittsburgh, Pennsylvania dUPMC, Office of Advanced Practice Providers, Pittsburgh, PA

eOncology Nursing Society, Pittsburgh, PA

rresponding author: Grant R. Martsolf, ail address: [email protected] (G.R. Mar 554/$ -see front matter � 2020 Publishe //doi.org/10.1016/j.outlook.2020.03.001

A B S T R A C T

Nurse practitioner (NP) employment in specialty practice areas, such as subspe- cialty ambulatory practices and inpatient units is growing substantially. The Con- sensus Model provides guidelines to help states aligning NP education and certification with specialty practice area. Despite expansion of the Consensus Model, significant misalignment exists between specialty NPs’ education, certification, and practice location. Therefore, further implementation of the Consensus Model across states could have significant impact on health systems and NPs working in specialty settings. More than 10 years after its introduction, it is time to evaluate the policy and practice implications of the Consensus Model. Important next steps include examination of the impact of the Consensus Model and how to help health systemswith alignment when and if theModel is more widely implemented. Cite this article: Martsolf, G.R., Gigli, K.H., Reynolds, B.R., & McCorkle, M. (2020, July/August). Misalign-

ment of specialty nurse practitioners and the Consensus Model. Nurs Outlook, 68(4), 385�387. https://doi.

org/10.1016/j.outlook.2020.03.001.

A R T I C L E I N F O

Article history: Received 24 February 2020 Accepted 1 March 2020 Available online June 24, 2020.

Keywords: Nurse practitioners Health policy Nurses

3500 Victoria St, 315B, Pittsburgh, PA 15213. tsolf). d by Elsevier Inc.

The nurse practitioner (NP) role was developed in the late 1960s to improve access to primary care among vulnerable children. Loretta Ford, the first NP, devel- oped the role with Dr. Henry Silver, a pediatrician, at the University of Colorado. Dr. Silver and Ms. Ford pro- vided one of the earliest articulations of the NP role, “(NPs) provide comprehensive well-child care to well chil- dren and identify, appraise, and temporarily manage certain acute and chronic conditions of the sick child” (Silver, Ford, & Day, 1968). So, from its inception, the NP role was envisioned as a primary care, general practitioner. As healthcare changed over the subsequent 50 years,

the role of NP-as-generalist has changed significantly.

NPs increasingly specialize, now practicing in settings including subspecialty ambulatory practices and inpa- tient units. NP employment in physician specialty practi- ces rose significantly between 2008 and 2016, when the percentage of specialty practices that employ at least one NP rose from 14% to 19%, a 35% increase (Martsolf et al., 2018). Today, less than 30% of NPs consider their principle practice role to be in primary care (American Association of Nurse Practitioners, 2019). As NP practice became more specialized, nursing

schools responded by increasing the variety of NP degree programs offered. In 2009, a National Organization of Nurse Practitioner Faculties study highlighted the

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disparate approach schools took to NP preparation (Scheibmeir, 2009). Of more than 1,000 NP clinical pro- grams, nearly 40% of all programs had a clinical designa- tion of “other specialties,” which included such specialties as forensics, neuropsychiatry, occupational health, pulmonology, and nephrology. There was very little standardization in terms of core competencies and graduation requirements. Often, it was unclear which NP certification exams graduates from “other specialty” programs qualified for or how states would endorse licensure. In response, the Advanced Practice Registered Nurse

(APRN) Consensus Work Group and National Council of State Boards of Nursing developed The Consensus Model for APRN Regulation: Licensure, Accreditation, Certi- fication, and Education. The “Consensus Model” attempts to (1) define APRN licensure, roles and population foci; (2) standardize education and certification; and (3) out- line a strategy for state-by-state implementation of alignment between education, certification, licensure, and practice role and setting (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). The Consensus Model provides guidelines for aligning NP education and cer- tification with practice. Most states have adopted some aspects of the Consensus Model but only a minor- ity have fully implemented it as originally conceived, particularly the guidelines for alignment. (National Council of State Boards of Nursing, 2020). Despite movement toward the Consensus Model,

anecdotal evidence, through conversations that we have had with NP leaders across the country, suggests that there remains significant misalignment between specialty NPs’ education, certification, and practice location. There is very little empirical evidence of the extent of misalignment but one paper suggests that less than 50% of all pediatric intensive care units even require their NPs to be certified in acute care (Gigli, Dietrich, Buerhaus, & Minnick, 2018). The issue of misalignment is largely driven by the

large number of Family NPs, a primary care specialty, that nursing schools graduate every year. Approxi- mately 70% of all new NP program graduates and newly certified NPs are Family NP certified (American Association of Colleges of Nursing, 2018; American Association of Nurse Practitioners, 2019). There are likely too few programs that educate other NP special- ties to meet burgeoning demand for specialty care. For example, there are nearly 10 times more family NP (FNP) programs than pediatric acute care NP programs. Furthermore, many non-FNP programs are having trouble recruiting students into their programs (Freed et al., 2015). This may be partially driven by the fact that many NP students enter FNP programs because they perceive that they will be more versatile and mar- ketable. This belief may be reinforced or otherwise not disabused by nursing schools and the nursing commu- nity at large. Given the large number of Family NPs currently in

the workforce, further implementation of the

Consensus Model across states could have significant impact on health systems and NPs working in spe- cialty settings. States can use implementation of the Consensus Model as a lever to push health systems to address misalignment. In fact, some states that adopted the Consensus Model have already done this (Gonzalez, 2017). For example, in 2007 the Texas legis- lature enacted legislation standardizing requirements for education and national certification consistent with the Consensus Model. In response, health systems moved toward education, certification, and practice alignment for all NPs by 2011, without a grandfather- ing clause, to be responsive to the regulatory expecta- tions of the state Board of Nursing (Board of Nurse Examiners, 2007; Gonzalez, 2017). Additionally, accred- itation organizations (e.g., The Joint Commission) require health systems credential providers in accord with state regulations, making regulatory require- ments for NP alignment a critical level for health sys- tems to maintain viability (The Joint Commission, n.d). More than 10 years after its introduction, it is time to

evaluate the policy and practice implications of the Consensus Model. Important next steps include exami- nation of the impact of the Consensus Model. As little is known about the scope and scale of NP misalignment, the first steps involve assessment of current practices. Conversations with hospital advanced practice man- agers and executives can provide insight to the practi- calities, opportunities, and challenges of achieving widespread alignment. Nurse educators and adminis- trators play a key role in preparing and providing the right mix of NP roles and skills. Their engagement can identify barriers to developing needs-driven education for the NP workforce of the future. The most important implications relate to safe, high-quality patient care delivery. Evaluation of patient outcomes as they relate to NP misalignment will also be essential. Findings can be used to forecast the future effects expansion of the Consensus Model would have on the NP workforce. Then, nursing leaders and professional organizations can use data to provide a vision of how to move for- ward with The Consensus Model in this light of a chang- ing regulatory landscape and practice needs.

R E F E R E N C E S

American Association of Colleges of Nursing. (2018). Enrollment and Graduations in Baccalaureate and Graduate Nursing Programs. Retrieved fromWashington, DC.

American Association of Nurse Practitioners. (2019). NP Fact Sheet. Retrieved from https://www.aanp.org/all- about-nps/np-fact-sheet.

APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus_Model_for_APRN_ Regulation_July_2008.pdf

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Board of Nurse Examiners. (2007). Summary of results. Retrieved from https://www.sunset.texas.gov/public/ uploads/files/reports/Nurse%20Examiners%20SOL %202007%2080%20Leg.pdf

Freed, G. L., Moran, L. M., Dunham, K. M., Hawkins- Walsh, E., Martyn, K. K., & Research Advisory Committee of the American Board of Pediatrics. (2015). Capacity of, and demand for, pediatric nurse practitioner educational programs: amissing piece of the workforce puzzle. Jour- nal of Professional Nursing, 31(4), 311–317.

Gigli, K. H., Dietrich, M. S., Buerhaus, P. I., & Minnick, A. F. (2018). Nurse practitioners and interdisciplinary teams in pediatric critical care. AACN Advanced Critical Care, 29 (2), 138–148.

Gonzalez, J. (2017). Primary care versus acute care nurse practitioner scope of practice: does the difference mat- ter. Retrieved from https://cdn.ymaws.com/www.tex asnp.org/resource/resmgr/2017_fall_conference_hand outs/S36_Gonzalez.pdf

Martsolf, G. R., Barnes, H., Richards, M. R., Ray, K. N., Brom, H. M., & McHugh, M. D. (2018). Employment of advanced practice clinicians in physician practices. JAMA Internal Medicine, 178(7), 988–990.

Scheibmeir, M. (2009). Clarification of nurse practitioner spe- cialty and subspecialty clinical track titles, hours, and credentialing, National Organization of Nurse Practi- tioner Faculties.

Silver, H. K., Ford, L. C., & Day, L. R. (1968). The pediatric nurse-practitioner program: expanding the role of the nurse to provide increased health care for children. JAMA, 204(4), 298–302.

The Joint Commission. (n. d.)Ambulatory care program: the who, what, when and where’s of credentialing and privileging. Retrieved from: https://www.jointcommis sion.org/-/media/deprecated-unorganized/imported- assets/tjc/system-folders/blogs/ahc_who_what_whe n_and_where_credentialing_bookletpdf.pdf? db=web&hash=CD838EB80D69FE2FA517285B4F3A0537