3: THE EVOLUTION OF ADVANCED PRACTICE NURSING ROLES ■ 93utilization of services, self- reported health status and physiological measures related to
diabetes, hypertension, and asthma outcomes (Lenz et al., 2004; Mundinger et al., 2000).
Oliver, Pennington, Revelle, and Rantz (2014) found significantly improved health out-
comes in Medicare and Medicaid patients in states where NPs have full, unrestricted
practice authority.
In another large randomized controlled trial of 2,957 low- income, low- risk women,
Jackson et al. (2003) found that birth outcomes of women receiving nurse- midwife col-
laborative care were equivalent to the group of women receiving traditional physician
care, but had lower operative intervention, lower use of epidural anesthesia, more
spontaneous vaginal deliveries, and less use of medical resources. Pine et al. (2003)
and Jordan et al. (2001) studies of anesthesia morbidity and mortality, noted earlier,
demonstrated in a similar fashion the effectiveness, safety, and quality of nurse anesthetist–
delivered care. Both historical and recent literature continue to document the effective-
ness of APN- provided care across multiple, diverse populations and in a diverse array
of settings.
■ APRN CURRENT AND FUTURE OUTCOMES
Providers and researchers must, and are, extending the quality focus to a rigor-
ous assessment of the influence of APRN- provided care across the health care sys-
tem, including primary, acute, and specialty practice. There is evidence, evolving
over several decades, that nurse anesthetist– provided care has resulted in high-
quality patient outcomes that are at least equivalent to those achieved by physi-
cians (AANA, n.d.). In addition, CNM- provided maternity care in the United States
has resulted in excellent neonatal and maternal outcomes, including physical health
of mothers and infants, and satisfaction with care, among others (Davidson, 2002;
Oakley et al., 1996; Wilson, 1989). Overall, NP- directed care has achieved excellent
outcomes, including care quality, cost- effectiveness, length of stay, and equivalence
to physician- provided care (Lenz et al., 2004). However, all of these findings should
be considered in the context of a changing health care system and rapidly changing
population demographics.
Primary care needs of the population are expanding in an era of significant health
reform, and many more primary care providers will be required to fill these needs.
Management of chronic illness is a growing APRN focus, as the burden of chronic
illness grows in our society. This is magnified by an increasingly aged population, by
evolutionary technologies that extend life across the developmental continuum, and
by health care reform that further pressures the economic bottom line, while addi-
tionally emphasizing chronic care management, medical homes, and primary care
access (Blumenthal, Abrams, & Nuzum, 2015; Kocher, Emmanuel, & DeParle, 2010).
APRNs are increasingly responsible for caseloads of chronically ill clients who have
complex social, behavioral, mental health, and medical needs in primary, acute, and
long- term care. Evidence of quality and effectiveness of APRN- provided care in past
five decades is strong. The evidence foundation for outcomes of care as provided
by NPs, CNMs, CRNAs, and CNSs, including their impact on client health in the
short- and long- term, utilization of services, cost, access, quality, and other factors,
should, and will, continue to grow in the now- transformed health care system of the
21st century.