Ongoing national challenges in emergency care delivery (Baugh et al., 2020; Chou et al., 2020; Diaz & Pawlik, 2020; Wallace et al., 2020) have emphasized the importance of using emergency nurse practitioners (ENPs) to the full scope of their experience and educational preparation. National workforce studies demonstrate a shortage of emergency health care providers in rural areas (Bennett, 2020; Marco, 2021; Muelleman et al., 2010) and further highlight the need for increased ENP utilization. However, barriers to ENP practice continue to evolve and are centralized around several key themes: confusion about NP roles among employers, variability in recognition of the ENP as a specialty, and reimbursement. Recognition of these barriers has led to national discussions exploring positioning the ENP role as a population focus within the Advanced Practice Registered Nurse (APRN) Consensus Model. Working with a diverse group of national stakeholders, the American Academy of ENPs (AAENP) performed an analysis of the ENP position within advanced practice nursing and the broader emergency care team to better understand the strengths, weaknesses, opportunities, and threats (SWOT) to the ENP role and to inform future research.
In 2006, the National Council of State Boards of Nursing (NCSBN) and other APRN stakeholders spearheaded a joint effort to align NP licensure, accreditation, certification, and education (LACE). The work from this stakeholder group culminated in the publication of the Consensus Model for APRN Regulation (NCSBN, 2008). Before publication of the Consensus Model for APRN Regulation (2008), NPs with multiple certifications (e.g., adult or pediatric acute care NPs, primary care pediatric NPs, and family NPs) were providing emergency care across the country (Hoyt et al., 2018). The availability of health care providers, need for cost-effective, accessible emergency care, and increasing emergency patient volumes across the nation shape current NP practice in emergency care settings. These needs are perhaps most significant in critical access and rural areas where access to health care is most limited. Nurse practitioners in emergency settings provide unique care, which spans "patients across the continuum of both lifespan and acuities" (AAENP, 2018a, pg. 1). The essential competencies for ENP practice delineate the unique knowledge, skills, and abilities needed for safe delivery of emergency care among patients with varied degrees of complexity and physiologic stability (American Academy of Emergency Nurse Practitioners & Emergency Nurses Association, 2021).
Given the uniqueness of practice among ENPs, this model has proven challenging for ensuring continued legitimization and regulation of the ENP workforce. Currently, the ENP is a specialty that builds on the education and competencies of the FNP. Therefore, ENP practice is ultimately guided by these statements in the Consensus Model:
* Scope of practice is not based on the practice setting, but instead on the patient's condition and health care needs;
* APRN specialty practice builds on the role and population focus;
* State licensing boards of nursing should not regulate practice at the specialty level.
As the specialty organization representing NPs in emergency care, AAENP has led collaborative efforts to ensure the establishment of a scientific foundation for education, certification, and regulation of NPs providing emergency care across the lifespan (AAENP, 2018a) including:
* Scope & Standards for Emergency Nurse Practitioner Practice (AAENP, 2016);
* Competencies for the Emergency Nurse Practitioner (AAENP, 2018b; AAENP & ENA, 2021);
* ENP Academic & Fellowship Program Validation Standards (AAENP, 2020);
* Specialty Certification Examination, available through the American Academy of Nurse Practitioners Certification Board;
* Publication of the Emergency Nurse Practitioner Core Curriculum text (Holleran & Campo, 2022).
Despite the direction of the Consensus Model and delineated foundations for ENP education and practice, many barriers in recognition of ENP as a specialty practice continue to emerge. Although ENP education is aligned across academic programs and with certification, there is a lack of uniformity among regulators, health insurance providers, and employers in acknowledging the ENP specialty. This lack of acknowledgment has created confusion, which challenges sustainability of ENP practice and patient access to care. The Institute of Medicine (2011) has encouraged state legislatures to adopt the NCSBN Model Act (National Council for State Boards of Nursing, 2021a) which addresses State Board of Nursing structure and defines nursing scope of practice, and the Model Rule (National Council for State Boards of Nursing, 2021b) which outlines standards of practice for nurses and boards of nursing, and directed educational funding only to those states that adopt the Model Act and Model Rules. However, within the Model Act and Rules (2021a, 2021b), there is no framework for nursing regulatory bodies to recognize or acknowledge APRN specialty practice. With lack of recognition for APRN specialties among national-level regulatory documents, State Boards of Nursing are left without direction for regulation of specialty APRN practices, enhancing the potential for marginalization of not only the ENP but also other APRN specialties as well. To further understand the challenges and opportunities, it is essential to examine stakeholder perceptions and views. This study aimed to explore stakeholder perceptions of the ENP specialty and potential move to an APRN population.
Methods and results
A SWOT analysis offers a simple conceptual framework that can assist decision-makers in considering how a change can affect the future and in formulating strategy. To explore the effect of moving the ENP to the population level on the APRN Consensus Model, a SWOT analysis was performed in the Spring of 2022 with a diverse stakeholder group representing broad geographic and practice settings. Nineteen stakeholders were invited, and all ultimately participated in this SWOT analysis hosted by AAENP. Selected individuals from previous stakeholder discussions hosted by the Emergency Nurses Association and AAENP were invited to participate. These stakeholders represented clinical practice, executive-level leadership, NP employers, academic program faculty, and national NP certifiers, and all stakeholders were either invited professional organization leaders or AAENP Board Members. The resulting group represented 13 states (Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Idaho, Maryland, Mississippi, Tennessee, Texas, Washington, and Wyoming) and diverse emergency care practice settings (inner-city trauma centers, urban medical centers, urgent care clinics, telemedicine, homeless shelters and federally designated critical access, and frontier and rural emergency departments).
First, stakeholders were divided into four teams, representing LACE. Within each team, the stakeholders researched one component of the LACE model and performed a SWOT analysis of the implications for the potential ENP reclassification to an APRN population from this perspective. Then, all stakeholders met together and, through consensus, determined the relative importance and generalizability of items within each team's SWOT analysis. Any perceived omissions in the analyses were discussed by the group and consensus reached. The identified SWOT of placing the ENP at the population level of the Consensus Model are listed in Tables 1 and 2.
Strengths and opportunities of emergency nurse practitioner as a population
A rigorous educational infrastructure for graduate- and postgraduate-level ENP specialty education has been established nationally (Ramirez et al., 2018; Wilbeck et al., 2020). Although ENP specialty educational programs are aligned through a national validation program (AAENP, 2020), this analysis revealed barriers to ENP practice at the specialty-level stem from the lack of regulatory acknowledgment. Moving the ENP to the population level would support alignment of educational qualifications for ENP licensure consistent with all other APRNs at the population level, and it would foster regulatory uniformity among state jurisdictions. Now is an optimum time for this transition because academic programs nationally are currently in a process of redesign to meet updated AACN Essentials (American Association of Colleges of Nursing, 2021), National Task Force (NTF) criteria (NTF, 2022), and competency-based education initiatives (Chekijian et al, 2020).
Recognition of the ENP as a population would help mend the varying levels of fragmentation and disorganization within the ENP workforce. Without complete adoption and implementation of the APRN Consensus Model, each state independently interprets the scope of practice and recognized roles for NPs. Employers are left to select and hire NPs based on their population certification and licensure with little guidance and understanding of alignment to specialty practice. Although some employers have elected to hire adult-gerontology acute care NPs (AG-ACNPs), the scope of practice for an AG-ACNP limits their practice to treating only adult patients with complex and technology dependent needs (Adult-Gerontology NP Competencies Work Group, 2016). By contrast, others will only hire NPs who hold dual certification and licensure as both FNP and AG-ACNP. This confusion is only amplified within critical access and rural hospitals where NPs may staff not only the emergency care settings but also provide primary care within a nearby clinic and serve as a hospitalist in their rural setting. This lack of uniformity in employment and credentialing specialty ENPs has significant implications for the emergency care workforce and has led to a national debate on the ENP specialty (Evans et al., 2020). Identification of a population that encompasses both the lifespan and acuities served within emergency care may also better support payer reimbursements (Chekijian et al, 2020).
From the employer standpoint, risk management provides the lens for credentialing. Credentialing and privileging, the processes used by hospitals and health insurance providers to ensure professional competence, were identified as another threat to ENP practice. Organizations also use this process to determine scope of practice parameters. In the credentialing and privileging process, ENPs are required to present documentation of training, certification, and licensure. Although there are general standards for the credentialing and privileging process, there is large variability in the administrative processes of hospitals and health insurance providers. In preparation for this SWOT analysis, stakeholders identified that many health care organizations will not credential and provide privileges to ENPs. This practice is perpetuated because of the inability to obtain licensure based on a specialty certification, such as the ENP-C. Emergency nurse practitioners are provided with the credentials and privileges of an FNP, consistent with the license issued by the State Board of Nursing. On the contrary, other organizations may credential ENPs to practice to the level of their specialty education and certification. This variability in credentialing and privileging leads to inconsistencies in the delineation of clinical privileges and utilization across health care organizations and states. Unnecessary restriction to clinical privileges results in inappropriate and underutilization of valuable clinical resources.
In these cases, misuse of credentialing and privileging erects barriers to ENP practice that would be overcome by a population-level certification. Should the ENP be recognized as a population, states are given the opportunity to license NPs based on certification, in accordance with the Consensus Model. This not only allows employers to hire the appropriately educated NP, and it also provides a framework for accreditors such as The Joint Commission and the American Nurses Credentialing Center (ANCC) to adopt clearer standards for credentialing and privileging NPs (Hoyt et al., 2021).
Weaknesses and threats of emergency nurse practitioner as a population
With current ENP preparation that builds on top of the family NP education and certification, providers are prepared to deliver broad care in both primary care and emergency settings. This flexibility in practice settings is helpful especially in more remote areas. One of the more concerning threats of moving the ENP to a population level is the potential limitation in access to not only emergency care but also the inpatient and primary care services provided by NPs in frontier, rural, and critical access areas.
Within the areas of accreditation and certification, a shift to population-level regulation for the ENP represents a substantial change for existing academic (and even postgraduate fellowship) programs, which will require institutional resources (primarily human and financial) to comply with accreditation standards. The financial impacts will not only involve educational programs but also the accrediting and certification programs who will ultimately be tasked with creating new processes and program changes. For example, modifications to the existing ENP certification program by examination eligibility requirements would be needed. Restricting certification eligibility to those individuals who have completed an accredited graduate-level academic program would negatively affect the ENP workforce in the immediate period. In addition, for individuals with academic preparation for dual roles (eg., FNP/ENP), certifications for which they are eligible may be deferred because of expense of certification and maintenance requirements.
From an educational standpoint, the transition from specialty NP to population NP education will require that existing specialty ENP programs revise curricula to incorporate the foundational core NP content currently taught within the population basis. These curricular revisions will require additional expense and effort of existing specialty ENP programs. In addition, in congruence with National Task Force (2022) criteria, faculty teaching in ENP programs should maintain practice within the population, and the program director, at a minimum, must hold doctoral preparation and national certification in the same population area (Criterion I.F.). For program accreditation, current specialty-certified ENP faculty will need a mechanism to obtain certification as an ENP at the population level.
To prevent these limitations, opportunities for grandfathering of currently practicing NPs in emergency care settings must be ensured. Although educational preparation as an ENP at the population level can be ensured for future state, deliberate and nationally recognized mechanisms (i.e., formalized grandfathering) must be available before changes in the Consensus Model to avoid limitations in access to care created by no longer recognizing the existing practicing and certified ENPs. This option would not be unique to the ENP role because the process has been previously with the advent of new NP populations and is clearly delineated by the National Council of State Boards of Nursing (NCSBN, n.d.). Currently certified ENPs may be required to retest or lose current certification. In addition, development of new curricula (e.g., certification-alignments postgraduate programs) for those currently in practice (Tennyson & Smallheer, 2022) will likely be needed.
With increased awareness of NP practice in emergency care, concerns from nursing and medicine colleagues (Berlin, 2018; Greene, 2018; Klein, et al, 2020) have amplified the misalignment and confusion felt by regulatory bodies such as the State Boards of Nursing. The regulatory landscape for APRN licensure and specialty recognition is one of the most immediate concerns that was discovered. Most threatening to specialty ENP practice are the restrictions imposed by regulatory bodies, employers, and insurers based on interpretations of the Consensus Model. Adhering to the Consensus Model, regulatory bodies do not recognize, or regulate, the ENP specialty. In addition, some employers and health insurance providers are hesitant to recognize the ENP specialty because certification cannot lead to licensure. One response to these threats is the movement of ENP practice to the population level, so that boards of nursing will recognize the ENP certification.
Conclusion
The ENP specialty is a unique and differentiated sector of the health care workforce that has rapidly evolved and contributed to the efficiencies of emergency care across the nation (Mafi et al., 2022). As some states recognize neither the Consensus Model nor the specialty certification examination, continued advocacy for the care provided by specialty-trained NPs in emergency care is critical.
Since the 2008 Consensus Model limits regulation to the APRN population level, it does not provide the framework to support ENP specialty practice across lifespan and acuities, ultimately leading to a lack of regulatory oversight and variances in licensure. Numerous obstacles, both internal and external, may compromise a health care organization's ability to effectively deploy and fully leverage the unique skills of ENPs, ultimately affecting patient access to care. As one of the largest NP specialties, a tremendous opportunity exists to promote consistency in regulation and credentialing, which supports interprofessional practice and understanding of who and what ENPs do. Although a shift from specialty to population-level practice for the ENP helps to legitimize the role and provides standardization for regulation and licensure, there remain consequences with this move that will affect the NP workforce broadly.
Any changes to the Consensus Model for APRN Regulation must be cautiously and extensively studied to ensure unintended consequences do not further threaten patient access to care. One must ask what precedent this change would set for other NP specialties, and where the line will be drawn. The determination of best placement for emergency care NPs within the Consensus Model remains to be determined, but with continued exploration, involvement of stakeholders, and central focus on supporting patient outcomes, the opportunities and challenges ahead may be successfully navigated.
Acknowledgments: The authors acknowledge the American Academy of Emergency Nurse Practitioners (AAENP) Board of Directors, as well as national experts and stakeholders, who have provided invaluable insights and feedback to support preparation of this manuscript.
Authors' contribution: Jennifer Wilbeck wrote the initial outline and draft and collated all revisions. All other authors revised the manuscript, located references, and assisted with final manuscript preparation.
References