86 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
- and continues to expand in response to current health care needs nationally and
globally.
Federal funding through Title VIII of the Nurse Training Act (American Association
of Colleges of Nursing, 2009) provided opportunities for the expansion of NP use in family-
focused primary care, in women’s health, and then in other populations. In addition, regional
programs funded by the federal Title X family planning initiative prepared NPs, therefore
significantly expanding the NP workforce in women’s health (Bednash, Worthington, &
Wysocki, 2009; Manisoff, 1981). By 1978, the IOM had taken the stand that state regulations
should be revised to accommodate an increased scope of practice and prescription authority
for NPs, albeit under physician supervision (Mason et al., 2000). As the advanced nursing
role began to fully take hold, university- based schools of nursing began to integrate NP
education and training at the graduate level. Title VIII funding was essential in supporting
nurses’ completion of these programs (AACN, 2009), and thus, expanded the advanced
practice nursing workforce. Scope of practice expanded beyond family and pediatric foci,
and beyond primary care to include adult health, as well as highly specialized and/ or sys-
tem- focused practice (e.g., oncology, cardiology, and psychiatric specialties).
Coincidentally, a variety of forces created opportunities for expansion of the NP
role. There were regulatory changes for medical education, including pass- through fund-
ing adjustments and state- level regulatory restrictions for physician residency training
of physicians (hours permitted on duty). There was also a growing body of evidence
supporting cost and treatment outcome effectiveness of NPs, as well as a growing and
better educated NP workforce. Along with other forces, these recognized improvements
created opportunities for greater inclusion of NP scope and practice into high acuity
patient care. As fewer physician residents were able/ available to provide acute patient
care coverage, additional opportunities for NP employment developed (American
Academy of Pediatrics Committee on Hospital Care, 1999; American Academy of
Pediatrics Committee on Pediatric Workforce, 2003). Adult, pediatric, and neonatal acute
care NP education was introduced and solidified, as nurse clinicians were poised to fill
gaps in the acute care system (Hinch, Murphy, & Lauer, 2005). In the 1990s, the National
Council of State Boards of Nursing (NCSBN); American Academy of Nurse Practitioners
Certification Board; American Nurses Credentialing Center; National Certification Board
for Pediatric Nurse Practitioners and Nurses, now the Pediatric Nursing Certification
Board (PNCB); and National Certification Corporation (NCC) began to jointly consider a
cohesive approach to regulation of NP practice (NCSBN, 1998).
The NP movement, particularly in its overlap with medicine’s functions, created
and continues to create controversies both within and outside of its own discipline.
The IOM’s landmark report The Future of Nursing: Leading Change, Advancing Health
(IOM, 2010) calls for nurses to practice to the full scope of their skills and full extent
of their education, as equal partners in both designing and providing health care serv-
ices. Great strides have been made toward this goal. According to Stanley (2012), the
consensus model for advance practice registered nurse (APRN) regulation (described
later in this chapter) demonstrates the evolving leadership roles that advanced practice
nurses (APNs) are taking on in the redesign of the U.S. health care system. In 2015, 21
states allowed NPs to have full, independent practice authority by statute and/ or regu-
lation. The VA now advocates for all advanced practice nurses in all specialties to have
full practice authority across all VA facilities in the United States. NPs continue to press
legislative initiatives promoting full practice authority on the federal and local levels.
Educational preparation, and qualifications for practice, role functions, and differentia-
tion from other providers (e.g., physicians, physician assistants, and CNSs) are among
the areas continuing to need clarification for legislation, regulation, and reimbursement.
NP practice has expanded beyond health professions, shortage areas into the mainstream