For the last 10 years, advanced practice nurses have been adapting to the recommendations of a professional consensus document that impacted practice, education, and regulation. The 10-year mark seems a good time to look at the document with a critical eye. Created to find common ground among advanced practice nurses and associated educational, professional, and regulatory interests, the Advanced Practice Registered Nurse (APRN) Consensus Model (Model) was adopted in 2008 (https://ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf). The Model defined 4 advanced practice nursing roles-clinical nurse specialist (CNS), nurse practitioner, nurse midwife, and nurse anesthetist-and outlined the educational and regulatory requirements for each role. An implementation effort followed, called LACE because its mission was to align APRN education programs (E) and corresponding program accreditation (A) with professional certification options (C) for the purpose of legislative regulation (L). The Model and LACE initiative have accomplished some important milestones for advanced practice. For CNSs, a primary gain was the acknowledgement of CNSs as APRNs and the move to title protection in all states. As could be predicted, such a sweeping effort also had unforeseen negative consequences. For CNSs, a negative outcome was tying regulation to certification, which marginalized an experienced CNS workforce because advanced level CNS certification options were (and are) limited, and requirements for current examinations are out of alignment with prior education preparation. The nuances of the positive and negative outcomes of the Model for CNS practice and education are complex. Likewise, each APRN role has its own critique of the positive gains and negative unintended consequences. For a group designed to set direction for the profession, LACE has a spotty history of transparency. The work is complicated, politically charged, and layered with conflicting interests. LACE has a public-facing information website, available at http://www.APRNLACE.org, but it appears there are no new postings for the past 2 years.
Despite APRN gains resulting from the Model and the LACE implementation work, and the many and varied critiques of the efforts, one topic needs to be addressed. The Model needs to ensure that the nursing profession meets its obligation to its social mandate. First articulated in 1980 by the American Nurses Association in Nursing's Social Policy Statement,1 the social mandate represents a contract between society and the profession of nursing. Renewed in all subsequent updates, the statement says that professional nursing, like other professions, is an essential element of a society, and that professions are dynamic, they develop and evolve within society, and they reflect and respond to that society's changing needs for their services. While professions are owned by a society, that society grants the professions authority and considerable autonomy over the structure and function of the profession. Thus, professions become self-regulating. The creation of the Model represents a form of self-regulation by the profession. In return, a profession is expected to act in the public trust and to use the resources of the profession to meet the need of the society for professional services. The public, through the legislature, may regulate a profession; it nonetheless is the responsibility of the profession to help guide regulatory efforts so the public benefits from the profession.
The profession partners with regulators to protect the public interest by ensuring that nurses meet minimum standards for practice, and incompetent and fraudulent providers are blocked or removed. Title protection is one regulatory mechanism for ensuring the public receives services from CNSs who meet specified qualifications. The profession also takes on promoting the public interest. Collectively, a profession, educational institutions, and regulatory bodies protect and promote the public's interest. However, protecting and promoting the public interest are also about promoting the profession's interest. Herein lies the juxtaposition of the APRN Model and the nursing profession's social mandate, requiring the right balance between regulation and the public interest. Excessive regulatory requirements can harm the public interest and interfere with nursing's responsibility to its social mandate.
As a regulatory guide, APRN Model has been criticized for being unnecessarily rigid. In addition to the 4 endorsed advanced practice roles, the Model specifies 6 clinical populations-neonate, pediatrics, adult/gerontology, psychiatry/mental health, gender health, and family health. The defining characteristics of the 6 populations lack a logical, organizing frame. Three of the populations are defined by developmental stage of life-neonate, pediatrics, adult/gerontology. Neonate is limited in age to the newborn, pediatrics includes birth to age 18 years, and adult/gerontology ranges from 14 years to end of the known human life span of roughly 100 years. Two populations are defined by the type problem-psych/mental health and gender health (women's health and men's health). And one population is defined by group-family health, which for all practical purposes is individual care for all age groups from birth to 100 years. Not all APRN roles have access to education, certification, and thus legal recognition in all 6 populations, limiting the practice options for some APRNs including CNSs. Limiting practice options results in limiting the profession's ability to meet the social mandate in some areas of public need.
The area of maternal-infant health is one example of the Model serving as a barrier to meeting the public need by limiting practice options. In the United States in 2016, only 23 states met the Healthy People 2020 target of 6.0 infant deaths per 1000 live births, with 10 states having rates between 7.4 and 9.1 (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm). Approximately 700 women in the United States die each year of pregnancy or pregnancy-related complications, with 72% of deaths due to 7 underlying causes that are largely preventable and manageable (cardiovascular and coronary conditions, cardiomyopathy, embolism, hemorrhage, infection, mental health conditions, and preeclampsia and eclampsia) (https://www.awhonn.org/page/MaternalMortalityRes). Maternal-infant care is distinctly different from neonatal, gender health (women's health) and adult/gerontology care even if the individuals fall within the developmental or problem categories of those sanctioned populations. Educational programs for maternal-infant CNSs have closed because of nonrecognition within the Model. Are other public needs for nursing services being compromised because the Model is the barrier? Arslanian-Engoren2 called upon the nursing community to reconsider the 6 established populations, noting that oncology and critical care, and perhaps other specialties, include patients with complex needs and a scope of research and knowledge that is correspondingly broad and deep. For these populations, experience alone is insufficient for an APRN specializing in that area. Gerontology, also a specialty with complex care needs and a significant knowledge base, was not well served by eliminating it as a population in the Model. Clinical nurse specialist colleagues who specialized in gerontology practice before it was blended into "adult-gerontology" complain that much depth of knowledge for practice has been lost, to the detriment of patient care. Specializing in a population of patients aged 14 to 100 years is, well, not really a specialty.
The challenges are many, but finding the right balance between requirements for education and regulation is critical. Nursing exists not for self-promotion, but to meet the needs of the public. Nurses are trusted caregivers, and we should likewise be trusted stewards of our profession, guiding it in service to the greater interest of the public. Clinical nurse specialists must be informed about the Model and the LACE initiative and call for greater transparency. The early efforts are a start at bringing the advanced practice nursing community together, but there is much work to do. A Model that insists on designated educational courses, required clinical practicum rotations, and limited certification examinations may not serve nursing's purpose in the end. Professions rise and fall in the context of economic conditions. Broadening the profession's ability to respond to the public is a better approach than creating narrowly defined requirements and overregulation. Unless we demand a model that protects the profession's ability to respond to the public need for nursing services, the scale will remain tipped on the side of self-promotion and obsolesce. History demonstrates that nurses are considered ethical, competent, caring professionals. A model for advanced nursing practice should take advantage of the public's trust in our profession.
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