3: THE EVOLUTION OF ADVANCED PRACTICE NURSING ROLES ■ 87of primary and acute care. Furthermore, NP clinicians, through their lobbying efforts, have
made inroads in reimbursement for the provision of health care services, such as the formal
ability to order durable medical equipment for their patients, the inclusion of NPs in the first
year of the Merit- Based Incentive Payment System (MIPS), and ensuring that NP- led patient-
centered medical homes are eligible to receive incentive payments for the management of
patients with chronic disease, all part of the sustainable growth rate repeal for Medicare
Part B. The American Medical Association (AMA), American College of Physicians, and
the American Academy of Pediatrics (AAP), among others, have periodically attempted to
limit NP scope of practice, particularly related to autonomous practice, through the creation
of policies and standards for physician supervision of nonphysician providers (Buppert,
2005; Hedger, 2009). The Federal Trade Commission (FTC), in a landmark report, Policy
Perspectives: Competition and Regulation of Advanced Practice Nurses (2014), encourages state
legislatures to look closely at state regulations for NP practice and notes that
Mandatory physician supervision and collaborative practice agreement
requirements are likely to impede competition among health care providers
and restrict APRNs’ ability to practice independently, leading to decreased
access to health care services, higher health care costs, reduced quality of
care, and less innovation in health care delivery. (FTC, 2014, p. 38)
The FTC policy paper cites research documenting that APRNs provide safe and
effective care within the scope of their training, certification, and licensure, noting
that, in addition, significant shortages of primary care practitioners can be alleviated
by reduction of undue regulatory burdens. NPs are still facing some challenges on the
federal and state levels, including current inability to certify their patients’ eligibility
for home health care services and permitting assignment of NP’s patients to Medicare
Shared Savings accountable care organizations (ACOs). In 2015, there is at minimum,
universal master’s preparation for NPs, and increasingly, NPs prepared at the doctoral
level, despite the fact that the DNP is not a requirement for entry into practice. In addi-
tion to post- master’s DNP program development, there has been a proliferation of BSN
to DNP programs across the United States.
■ DEVELOPMENT OF THE CNS ROLE
Concurrent with expansion of NP practice, programs preparing CNSs were prolifer-
ating. For example, the first CNS program in psychiatric nursing was established in
the 1954 at Rutgers University in New Jersey. Subsequently, CNS programs expanded
throughout the United States in the 1950s, 1960s, and later (MacDonald, Herbert, &
Thibeault, 2006). The CNS role was conceived and then further evolved to an advanced,
specialized, nursing clinician focused on expert practice, improvement of care at the
bedside, and intertwining roles as “clinician, consultant, researcher, educator and man-
ager” (Page & Arena, 1994, p. 316). More recent conceptualization of the “research”
function of the master’s- prepared nurse in an advanced role, regardless of specific role,
is translation and integration of evidence into clinical practice (AACN, 1996). In its evo-
lution, the CNS scope of practice would expand to include direct patient care services,
as well as staff education and macrosystem management of a specialized population,
embedded within a nursing or a systems model, rather than the medical model of care.
While the focus of NP practice was conceived as the individual at the direct
care level, the focus of CNS practice was to be both individual and macro levels, in
a specialized population (versus the generalist focus of the clinical nurse leader role),