O’Grady, Eileen T., 2008, Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality, An Evidence based Handbook for Nurses. Chapter 43. In Hughes, R.G. (Ed). Patient Safety and Quality: An Evidence-based Handbook for Nurses. (Prepared with support from the Robert Wood Johnson Foundation.) AHRQ Publication no. 08-0043. Rockville, MD. http://www.ncbi.nlm.nih.gov/books/NBK2641/ In this chapter, Dr. O’Grady reviewed more than 150 articles to learn what the literature revealed of the contribution of APRNs to patient safety and quality. She concluded that a number of informational or empirical issues were lacking in the APN evidence base of that period.

Hing, E. & Uddin, S. 2011 Physician Assistant and Advance Practice Nurse Care in Hospital Outpatient Departments: United States, 2008-2009. NCHS data brief, no 77. Hyattsville, MD: National Center for Health Statistics. The authors explain that APRNs and physician assistants care for patients in clinics that serve as a primary provider of care. They more often see patients in non-teaching hospitals and visits with a PA or APRN are more frequent in rural areas. This contradicts the contention by some physician groups that APRNs would not locate to rural areas and therefore cannot be a solution for lack of access to care in those areas. http://www.cdc.gov/nchs/data/databriefs/db77.htm

Report of the Committee on Geographic Adjustment Factors in Medicare Payment. 2012   This IOM report is part II of the Geographic Adjustment in Medicare Payment reports and it once again states that APRNs be allowed to practice to the full extent of their education. The Institute of Medicine of The National Academies, Geographic Adjustment in Medicare Payment – Phase II: Implications for Access, Quality, and Efficiency, July 17, 2012 http://www.iom.edu/Reports/2012/Geographic-Adjustment-inMedicare-Payment-Phase-II.aspx

Laidman, J., 2012, Nurses Remain Nation’s Most Trusted Professionals, Medscape Medical News Rating the honesty and ethical standards of health professionals, the public once again chose nurses as their highest rated profession. Nurses have led the rankings for eleven consecutive years , Dec 06, 2012. Available from with a Medscape account http://www.medscape.com/viewarticle/775758

When the Doctor Is Not Needed, editorial. December 15, 2012. The New York Times, Sunday Review, editorial. In this editorial and in the subsequent comments, the idea is advanced that APRNs and pharmacists and community aides can all contribute to reducing healthcare expenditures while increasing access to and ease of care. http://www.nytimes.com/2012/12/16/opinion/sunday/when-the-doctor-isnot-needed.html?_r=0

Adalja, A. Feb 2013, Sometimes the Best Medical Care is Provided by Those Who Aren’t MDs, Forbes, Capital Flows, OP/ED. This physician makes the case in a Forbes opinion piece that APRNs might serve provider roles where the expertise of a physician is not strictly required. He further asserts that licensing laws are barriers to utilization of these roles. http://www.forbes.com/sites/realspin/2013/02/10/sometimes-the-best-medical-care-is-providedbythose-who-arent-m-d-s/

New Era of Patient Engagement, Health Affairs Thematic Issue, February 2013. This article has excellent links to latest patient engagement literature. Retrieved from: http://www.chcf.org/publications/2013/02/health-affairs-patient-engagement#ixzz2LNKTUFC6

Huang, E.S. and Finegold, K. 2013. Seven Million Americans Live In Areas Where Demand for Primary Care May Exceed Supply by More Than 10 Percent, Health Affairs. Estimating the expansion of insurance coverage under the Affordable Care Act, the authors make a compelling case that some areas of the country are considerably more vulnerable to access issues than others. Retrieved from: http://content.healthaffairs.org/content/early/2013/02/19/hlthaff.2012.0913

Pittman, D., March 19, 2013. Doc Support for Patient Safety Movement Lags, Med Page Today. Dr. Lucian Leape, leader of the patient safety movement, calls for a federal patient safety agency. Despite the rhetoric from organized physician groups about needing a physician on every care team, Dr. Leape is quoted as saying, “We don’t do teams well.” “Doctors tend to feel they have an individual veto over safe practices. If they don’t agree with something, they feel they don’t have to follow it.” Retrieved from: http://www.medpagetoday.com/PublicHealthPolicy/Ethics/37956

Fostering Successful Patient and Family Engagement: Nursing’s Critical Role, A Whitepaper, 2013. Nursing Alliance for Quality Care. An expert panel composed this blueprint for improving and supporting nursing’s role in partnering with patients and families for optimal healthcare outcomes. Retrieved from: http://www.naqc.org/Main/Resources/Publications/March2013-FosteringSuccessfulPatientFamilyEngagement.pdf

Inglehart, J. May 16, 2013, Expanding the Role of Advanced Nurse Practitioners, the Risks and Rewards, a Health Policy Report. The New England Journal of Medicine. n engl j med 368; 20 nejm.org may 16, 2013.   In this important article, the emphasis is on the impending expansion of coverage under the ACA at the same time that a primary care physician shortage looms. Following the course set by the IOM Future of Nursing Report of 2010, APRNs have aligned education and certification, positioning themselves to assume a provider status alongside physicians. This possible solution to the access to care problem is met with resistance by organized medical groups. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMhpr1301084

Peterson L.E., Phillips, R.L., Puffer, J.C., Bazemore, A., Petterson, S., 2013. Most Family Physicians Work Routinely With Nurse Practitioners, Physician Assistants, or Certified Nurse Midwives. Journal of the American Board of Family Medicine. 2013; 26(3):244-245. This policy brief in the Journal of the American Board of Family Medicine describes the collaboration that occurs every day between primary care providers and APRNs in practice. In a 2011 survey 60% of respondents answered that they work routinely with APRNs. Retrieved from: http://www.jabfm.org/content/26/3/244.full.pdf

Report OEI-02-09-00603, 06/20/2013. Prescribers with Questionable Patterns in Medicare Part D, the Office of the Inspector General, U.S. Department of Health and Human Services. This study of Medicare Part D prescriber data analyzes the average number of prescriptions per beneficiary as well as the number of pharmacies associated with each prescriber, the percentage of scripts that are brand name and that are for schedule II or schedule III drugs. Prescribers are grouped as generalists or specialists and data is available for nurse practitioners and for physicians’ assistants. Retrieved from: http://oig.hhs.gov/oei/reports/oei-02-09-00603.asp

The Wall Street Journal, June 20, 2013. The Experts: What Should Be Done to Fix the Predicted U.S. Doctor Shortage? http://online.wsj.com/article/SB10001424127887323393804578555741780608174.html Eighteen experts outline their ideas for addressing a predicted physician shortage, particularly in primary care. Eleven stressed removing restrictions to APRNs.

Weston, M.J., Chief Executive Officer American Nurses Association; July 17, 2013. A letter to Honorable Marilyn Tavenner, MHA, RN, Centers for Medicare & Medicaid Services.   On behalf of the ANA Marla Weston proposes that Qualified Health Plans credential no less than 10% of the Medicare part B APRN count for that state, thus assuring adequate representation of APRNs in those exchanges. http://www.nursingworld.org/cms71913

Philipsen, N.C. & Haynes, D., January 2007, Making Nurses Mobile. The Journal for Nurse Practitioners. RN licensure has had a significant history of compact recognition. This article discusses advantages of development of compact license recognition for APRNs and how this would facilitate mobility for APRNs.


Hansen-Turton, T., Ritter, A., Rothman, N., & Valdez, B., 2006, Insurer Policies Create Barriers to Health Care Access and Consumer Choice. Nursing Economic$, Vol. 24, No.4, 204-211. Nurse-managed health centers deal with barriers that are related to scope of practice, inadequate legal protection, and discriminatory managed care policies. Conclusions based on information from 117 managed care plans in 47 states & DC. Companies with Medicaid beneficiaries are two times more likely to credential primary care NPs.

Hansen-Turton, T., Ritter, R. & Torgan, R., June 2008, Insurer’s Contracting Policies on Nurse Practitioners as Primary Care Providers: Two Years Later. Policy, Politics, & Nursing Practice, Vol. 9, 241-248. Nurse-managed health centers are part of the safety net providing care to underserved. An ongoing challenge for these clinics is obtaining reimbursement from third party payers. What progress occurred since this was first looked at is not attributable to regulatory changes or actions related to enforcement of existing laws. DOI: 10.1177/1527154408319450 Abstract http://ppn.sagepub.com/content/9/4/241.abstract

Lowery, B. & Varnam, D., 2011, Physician Supervision and Insurance Reimbursement: Policy implications for nurse practitioner practice in North Carolina. North Carolina Medical Journal, Vol. 72, No. 4, 310-313. Physician supervision of NP practice obscures NP care making it more difficult to identify who the actual provider was when looking at outcomes. Reimbursement for NP services is more restrictive when physician involvement in practice is required. http://classic.ncmedicaljournal.com/wp-content/uploads/2011/07/724-complete-issue.pdf

Chapman, S.A., Wides, C.D. & Spetz, J., 2010, Payment Regulations for Advanced Practice Nurses: Implications for Primary Care. Policy, Politics, & Nursing Practice, Vol. 11, No. 2, 89-98. APRN billing is difficult to track for Medicare since there is no mechanism to differentiate those billing “incident to” rather than under their own identifier. Challenges exist for APRNs to become credentialed with managed care plans. Research supports little difference in outcomes between APRNs and physicians but there is a general trend to reimburse these providers less than physicians. DOI: 10.1177/1527154410382458 Abstract http://ppn.sagepub.com/content/11/2/89.abstract

Pittman, P. & Williams, B. 2012, Physician Wages in States with Expanded APRN Scope of Practice. Nursing Research and Practice, Vol. 2012, Article ID 671974. Bureau of Labor Statistics was used to review primary care physician incomes in states with and without scope of practice barriers for APRNs. Finding was that there was no appreciable difference in physician wages. http://www.hindawi.com/journals/nrp/2012/671974/


Byren, W., 2011. US Nurse Practitioner Prescribing Law: A State-by-State summary. Dr. Byren has created an informative state by state summary of CNP prescribing laws. He attempts to update this information each year. Maps are available. Retrieved from (with Medscape account): http://www.medscape.com/viewarticle/440315

Nurse Practitioners Are In, and Why You May Be Seeing More of Them, February 13, 2013. Describing the state driven barriers to full practice by APRNs, this article also contends that commercial clinics run by APRNs are expanding and filling a need. The article stresses that retail clinic owners have an interest in removing these legislative barriers in states. Retrieved from: Knowledge@Wharton. http://knowledge.wharton.upenn.edu/article.cfm?articleid=3183

Rice, C. 2013. The Trouble with Nurse Practitioners. March 18, 2013. Health Leaders Media. The trouble with nurse practitioners is there are not enough of them for the needs ahead and added to that states restrict what they can do. Restrictive state policies are constraining available providers in some states. Retrieved from: http://www.healthleadersmedia.com/print/HR-290219/The-Trouble-with-Nurse-Practitioners

Applebee, J. April, 2013. Walgreens Becomes 1st Retail Chain To Diagnose, Treat Chronic Conditions, Kaiser Health News. Walgreens nurse practitioner run clinics will care for selected patients with chronic conditions. Walgreens runs in store clinics as well as about 350 clinics at worksites that are paid for by employers. Henry J. Kaiser Family Foundation. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/April/04/walgreens-primary-care-services.aspx

Reisman, A., April 18, 2013. Free the Nurses, One answer to our health care crisis: Let nurse practitioners do primary care on their own. The Slate Group, a Division of the Washington Post Company. Nurse practitioners and other APRNs can address the primary care gap and some physicians agree yet others reflect the medical society rhetoric that APRNs will not know when to see consultation or referral. In this article Dr. Reisman argues for lifting the barriers to APRN practice, particularly for those who would seek to do primary care. Retrieved from: http://www.slate.com/articles/double_x/doublex/2013/04/nurse_practitioners_should_do_primary_care_on_their_own.single.html

Rounds, L.R., et al. 2013 The Consensus Model for regulation of APRNs: Implications for nurse practitioners. Journal of the American Association of Nurse Practitioners 25 (2013) 180–185 John Wiley and Sons, Inc. Wiley online library. In this article Linda Rounds and Jolene Zych describe the elements of The Consensus Model as well as the intended impact on the regulation of APRNs. They illustrate that lack of uniformity in regulation across states can have the unintended consequence of restricting mobility of APRNs and access to their care. DOI: 10.1111/j.1745-7599.2012.00812.x Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/j.1745-7599.2012.00812.x/abstract

Wall Street Journal Reports June 13, 2013. Should Nurse Practitioners Be Able to Treat Patients without Physician Oversight? In this opinion piece in the Wall Street Journal Reports both a pro and con position is taken on the need of physician oversight of nurse practitioners providing patient care. Angela Golden of AANP makes the case for practice autonomy and Reid Blackwelder of the American Academy of Family Physicians argues that nurse practitioners are best used for monitoring the condition of stable patients. Retrieved from: http://online.wsj.com/article/SB10001424127887324715704578480911396098592.html?KEYWORDS=n urse+practitioners


Cost Effectiveness

Florida Tax Watch, November 2011, Expanding the Scope of Practice for Advanced Registered Nurse Practitioners and Physician Assistants Would Generate Fiscal Savings While Enhancing High Quality Medical Care. Reducing skyrocketing health care costs in Florida while maintaining effectiveness is becoming a top priority. This report considers whether expanding the role of the Advanced Registered Nurse Practitioner would make a viable difference. Conclusion is that utilization of NPs and PAs more fully would provide cost savings in Florida while continuing to provide high quality healthcare. http://www.floridataxwatch.org/resources/pdf/20111102ARNP.pdf

Bauer, J.C., April 2010, Nurse Practitioners as Underutilized Resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners, Vol. 22, No 4, 228-231. Cost effectiveness of care provided is one consideration for cost savings for our health care system. The author identifies multiple ways in which NPs are cost effective, which includes a lack of increase in either liability or malpractice claims. DOI: 10.1111/j.1745-7599.2010.00498.x

Perryman, M.R., 2012 APRN Utilization of Economic Import Report. This informative report by noted economist, Ray Perryman of The Perryman Group, demonstrated that fully utilizing APRNs in Texas would benefit their economy, create jobs, and make healthcare more widely available in their state. http://c.ymcdn.com/sites/www.texasnp.org/resource/resmgr/Advocacy/Perryman%20APRN%20Ultilization%20Economic%20Impact%20Report%20May%202012.pdf

The Perryman Report, http://m.news-journal.com/mobile/lindale/opinion/perryman-reportaprn-s-step-in-the-right-direction/article_1d52a7ef-f82a-59e2-8338-c330b5001d54.html



Hain, D. & Fleck, L.M., May 31, 2014, Barriers to NP Practice that Impact Healthcare Redesign. OJIN: Online Journal of Issues in Nursing, Vol. 19, No. 2, Manuscript 2. NPs continue to experience barriers to being able to practice to the full extent of their education and training. These include varying scopes of practice, challenges related to physicians or physician’s groups, and payment policies. Barriers may be addressed by policy and education. DOI: 10.3912/OJIN.Vol19No02Man02 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Barriers-to-NP-Practice.html

Brassard, A., July 2012. Removing Barriers to Advanced Practice Registered Nurse Care: Hospital Privileges. Home Health and Hospice Services. Public Policy Institute. AARP extensively reviews the potential barriers to full practice for APRNs in hospitals and argues for the extension of privileging and credentialing to these roles, illustrating the benefits to the interprofessional team, to hospital administrators, to insurers and to consumers when this occurs. http://www.aarp.org/health/medicareinsurance/info-07-2012/removing-barriers-to-advanced-practice-registered-nurse-care-home-healthhospice-AARP-ppi-health.html

Aizenman, N.C., 2013. Nurses can practice without physician supervision in many states. The Washington Post. APRNs are a resource that could be used presently to alleviate primary care access issues in many states. This article stresses the legislative attempts to accolish removal of barriers to APRN practice. Retrieved from: http://articles.washingtonpost.com/2013-03-24/national/37989896_1_nurse-practitioner-physician-primary-care-practices

Robert Wood Johnson, 2013, Charting Nursing’s Future (June, 2013). Improving Patient Access to highly Qualified Care: How to Fully Utilize the Skills, Knowledge, and Expertise of Advanced Practice Registered Nurses. http://www.rwjf.org/en/research-publications/find-rwjf-research/2009/01/charting-nursings-future-archives/improving-patient-access-to-high-qualitycare.html This very thorough report describes how APRNs can expand access to care, utilizing innovative models, and emphasizing the research on safety and quality in care provided by APRNs. They describe present barriers as legal/regulatory, institutional, and cultural.


Primary Care Provider

            Focus on NP (from non-nursing sources)

Naylor, M.D & Kurtzman, E.T., May 2010, The Role of the Nurse Practitioners in Reinventing Primary Care. Health Affairs, Vol. 29, No. 5, 893-899. Summarizes evidence supporting NPs ability to assist with improving primary care outcomes and cost utilization. To support this, standardizing nurse practice acts and establishment of comparable reimbursement for services provided are issues that need to be addressed. DOI: 10.1377/hlthaff.2010.0440 http://content.healthaffairs.org/content/29/5/893.full

Yee, T., Boukus, E.R., Cross, D., Samuel, D.R., 2013, Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies Laws Don’t Affect Services Provided by Nurse Practitioners but Do Limit Practice Opportunities. NIHCR Research Brief NO. 13. This report stresses the potential to utilize nurse practitioners in primary care and suggests policy makers may want to consider regulatory changes even beyond revising scope of practice laws, to grant direct payment to NPs under Medicaid.

Kuo, Y-F., Loresto, F.L., Rounds, L.R., & Goodwin, J.S., 2013, States with Least Restrictive Regulations Experienced the Largest Increase in Patients Seen by Nurse Practitioners. Health Affairs, 32, # 7 (2013): 1236-1243. Using Medicare claims data and Linda Pearson’s maps methodology for full practice applied to nurse practitioners, this demonstrated a 2.5 fold greater likelihood of Medicare beneficiaries receiving their primary care from an NP in states with less restrictive practice regulations than in the most restrictive states. Abstract http://content.healthaffairs.org/content/32/7/1236.abstract

Donelan, K., DesRoches, C.M., Dittus, R.S., & Buerhaus, P., 2013, Perspectives of Physicians and Nurse Practitioners on Primary Care Practice. A special article, The New England Journal of Medicine. May 16, 2013, n engl j med 368; 20 nejm.1898 org may 16, 2013. A study of primary care clinicians demonstrated disagreement between physicians and APRNs on their roles in primary care delivery. APRNs were less likely to believe that physicians provided higher quality examinations or consultation than APRNs. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMsa1212938

Fletcher, C., Copeland, L., Lowery, J., & Reeves, P., 2011, Nurse Practitioners as Primary Care Providers within the VA, Military Medicine, 176, 7:791. This study examined the perceptions of APRNs and physicians regarding APRN roles as primary care providers within the Department of Veterans Affairs. Findings suggested comparable outcomes for those treated for diabetes or hypertension. They further found that physicians underestimated what care APRNs performed independently.

Schiff, M., 2012. The Role of Nurse Practitioners in Meeting the Increasing Need for Primary Care, an NGA paper. The National Governor’s Association NGA Center for Best Practices. This paper suggests that states consider changing the scope of practice restrictions on nurse practitioners so they might practice fully in the provision of primary health care. http://www.nga.org/cms/home/nga-center-for-best-practices/center-publications/page-health-publications/col2-content/main-content-list/the-role-of-nurse-practitioners.html          

Focus on NP (from nursing sources)

Poghosyan, L., Lucero, R., Rauch, L., & Berkowitz, B. Dec 07, 2012. Nurse Practitioner Workforce, a Substantial Supply of Primary Care Providers. Nursing Econ. 2012; 30(5):268-274. With a thorough review of the issues this article once again notes that APRNs are uniquely suited to address the primary care access problems if barriers to their full utilization are lifted. With Medscape account http://www.medscape.com/viewarticle/773243

Murphy, K., 2011, Advanced Practice Nurses: Prime Candidates to Become Primary Caregivers in Relation to Increasing Physician Shortages Due to Health Care Reform . Journal of Nursing Law, Vol. 14 No. 3, 4 (2011) Springer Publishing Co. Mr. Murphy makes the case that APRNs can assume primary care provider roles and do so safely. He explains that APRNs can treat illness and teach wellness while realizing high patient satisfaction. Abstract http://dx.doi.org/10.1891/1073-7472.

            Information from Outside Nursing

Workforce Roles in Redesigned Primary Care, an executive summary. AHA Primary Care Workforce Roundtable. January 2013. The American Hospital Association. http://campaignforaction.org/sites/default/files/PCwhitepaper%20FINAL%20Jan102013.pdf

Blumenthal, D., & Abrams, M.K., May 16, 2013, Putting Aside

Preconceptions — Time for Dialogue among Primary Care Clinicians. NEJM editorial David Blumenthal and Melinda Abrams of the Commonwealth Fund describe the primary care roles that both APRNs and PCPs can provide while acknowledging differences in their training,. They advocate for cooperation and collaboration and patient preference in providing primary care services. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMe1303343

Carrier, E.R., Yee, T., Stark, L. December 2011, Matching Supply to Demand: Addressing the U.S. Primary Care Workforce Shortage. Policy analysis from National Institute for Health Care Reform. Focus on consideration of increasing access to primary care by changes in scope of practice policy for non-physician providers as well as suggesting consideration of payment restructuring to reimburse these providers. This includes some discussion of rural vs urban needs. http://www.nihcr.org/PCP_Workforce

Josiah Macy, Jr. Foundation, April 2010. Who Will Provide Primary Care and How Will They Be Trained? Proceedings of a conference chaired by Linda Cronenwett, Ph.D., R.N., FAAN and Victor J. Dzau, M.D. Discussion of challenges with primary care, including continued barriers for APRNs in form of regulations and reimbursement. Attendees agreed that development of team skills, representation of health needs of the public, and the expectation of contributing to continued improvement of the system are important expectations for all healthcare professionals. http://macyfoundation.org/docs/macy_pubs/JMF_PrimaryCare_Monograph.pdf


Acute Care

Kleinpell, R., Hudspeth, R., Scordo, K.A., & Magdic, K., 2012, Defining NP scope of practice and associated regulations: Focus on acute care. Journal of the American Academy of Nurse Practitioners 24, 11-18. This article discusses the role of acute care NPs in light of the Consensus Model. The emphasis is on what care the patient needs rather than the setting of the patient and the need for continued development of clarity of understanding about NP practice. DOI: 10.1111/j.1745-7599.2011.00683.x



Malina, D.P. & Izlar, J.J., May 31, 2014. Education and Practice Barriers for CRNAs. OJIN: The Online Journal of Issues in Nursing, Vol. 19, No. 2, Manuscript 3. The authors discuss multiple issues that have historically been issues for CRNAs. These include opposition from anesthesiologists, issues of reimbursement, faculty challenges, and scope of practice. DOI: 10.3912/OJIN.Vol19No02Man03

Kaplan, L., Brown, M-A., & Simonson, D., Feb. 2011, CRNA Prescribing Practices: The Washington State Experience. AANA Journal Vol. 7, No 1, 24-29. Washington state had a change in the nurse practice act that provided the opportunity for CRNAs to obtain prescribing authority including the opportunity to prescribe controlled substances. Of those who responded to the survey, 61% chose not to obtain prescriptive authority. Some of the reasons given were that someone else wrote prescriptions or that facility policies were more restrictive about prescribing. Changes anticipated by being able to prescribe included ability to prescribe in the absence of the surgeon, opportunity for pain management practice, improvement in patient care, and improved career mobility. http://www.aana.com/newsandjournal/Documents/crnaprescribing_0211_p24-29.pdf

Pine, M., Holt, K.D., Lou, Y-B., April 2003, Surgical Mortality and Type of Anesthesia Provider. AANA Journal, Vol. 71, No. 2, 109-116. Based on a retrospective evaluation of Medicare records, the authors found no statistically different results for mortality rates for anesthesia services in hospitals without anesthesiologists in comparison with hospitals with anesthesiologist only or anesthesiologist directed care. http://www.aana.com/newsandjournal/Documents/109-116.pdf

Izlar, J.J., 2014, Health care challenges to the certified registered nurse anesthetist as an advanced practice registered nurse. Clinical Scholars Review, Vol. 7, No. 1, 7-9. The IOM goal of the ability to practice to the full extent of education and training has many facets. CRNAs face challenges with their scope of practice, training opportunities, reimbursement for services, and inclusion in ACOs. DOI:  http://dx.doi.org/10.1891/1939-2095.7.1.7



Johantgen, M. et al. 2012 Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians. CNM Outcomes: A Systematic Review 1990-2008. Women’s Health Issues, 22(1), e73-381. In this review of publications using PubMed, CINAHL and ProQuest, similar results were found between CNMs and physicians for many infant outcomes but perineal laceration occurrence was lower and breast feeding rates higher for the CNM. DOI: 10.1016/j.whi.2011.06.005.

Declercq, E.R., Paine, L.L., Simmes, D.R. & DeJoseph, J.F. Mar/Apr 1998, State Regulation, Payment Policies, and Nurse-Midwife Services. Health Affairs, Vol. 17, No. 2, 190-200. Comparison of practice environments in 1991 and 1995 revealed a strong relationship between the number of CNMs in the state and the regulatory and reimbursement environments. States with more supportive environments had larger proportions of CNMs. DOI: 10.1377/hlthaff.17.2.190 http://content.healthaffairs.org/content/17/2/190.full.pdf+html

Walker, D., Lannen, B., & Rossie, D., May 31, 2014, Midwifery Practice and Education: Current Challenges and Opportunities. OJIN: Online Journal of Issues in Nursing, Vol. 19, No. 2, Manuscript 4. Challenges persist for midwives which include third party reimbursement, restrictions based on physician supervision, legislation about out-of-hospital births, and prescriptive authority in some places. DOI: 10.3912/OJIN.Vol19No02Man04 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-19-2014/No2-May-2014/Midwifery-Practice-and-Education.html



Lyon, B.L., 2004, The CNS Regulatory Quagmire: We Need Clarity About Advanced Nursing Practice. Clinical Nurse Specialist, Vol. 18, No. 1, 9-13. This was published prior to the APRN Consensus Model but highlights some of the issues the Model attempts to resolve. These include CNS title, regulation, certification exams, and meeting the needs of the future. http://journals.lww.com/cns-journal/Citation/2004/01000/The_CNS_Regulatory_Quagmire__We_Need_Clarity_About.4.aspx

National Association of Clinical Nurse Specialists, 2012, National Association of Clinical Nurse Specialist’s Statement on the APRN Consensus Model Implementation. Clinical Nurse Specialist, Vol. 26, Issue 3, 185-190. There are significant changes that will happen as the Consensus Model is implemented. Some states have taken the incremental approach to implementation of the Model. Educational and certification structures will need some changes to align with the Model. There are some references of articles about CNS practice included. DOI: 10.1097/NUR.0b013e3182561b24   http://journals.lww.com/cns-journal/Citation/2012/05000/National_Association_of_Clinical_Nurse.15.aspx

Lewandowski, W. & Adamle, K., 2009, Substantive Areas of Clinical Nurse Specialist Practice: A Comprehensive Review of the Literature. Clinical Nurse Specialist, Vol. 23, No. 2, 73-90. The literature provides conceptual basis for the CNS role. The role of the CNS needs continued evaluation, development, and definition as the Consensus Model implementation moves forward. Abstract obtainable from table of contents: http://journals.lww.com/cns-journal/toc/2009/03000


Outcomes of care

Newhouse, R.P et al, Sep-Oct 2011, Advanced Practice Nursing Outcomes 1990-2008, A Systematic Review. NURSING ECONOMIC$, Vol. 29, No. 5. This CNE series is a systematic review of APRN outcomes from 1990 through 2008. It concludes that the analysis “supports a high level of evidence that APRNs provide safe, effective, quality care to a number of specific populations in a variety of settings.” http://www.nursingeconomics.net/ce/2013/article3001021.pdf

Robert Wood Johnson Foundation Nursing Research Network Evidence Brief, May, 2011. Quality of Care Provided by Advanced Practice Registered Nurses. This research brief highlights studies of outcomes related to care by APRNs often comparing outcomes with care rendered by physicians. They found equal or better outcomes in these studies with patient satisfaction often being higher for the APRN group. http://campaignforaction.org/sites/default/files/Quality%20of%20Care%20Provided%20by%20Advanced%20Practice%20Registered%20Nurses.pdf

Robert Wood Johnson Foundation Nursing Research Network Evidence Brief, May, 2011. Costs of Care Provided by APRNs. In this brief research of cost savings associated with APRN care is highlighted. They concluded that costs overall were lowered while quality was maintained or improved. http://campaignforaction.org/resource/cost-care-provided-advanced-practice-registered-nurses-aprns


Population distribution

Skillman, S., Kaplan, L. et al, 2012. Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Data, ANA and WWAMI Rural Health Research Center, The Rural Health Final Report Series, Final Report #137. This study of the national provider identifier for APRNs it was found that 152,785 APRNS are in the US and that overall there are 3.6 urban to 2.8 rural NPs per 10, 000 population. Once again this counters the often cited argument by physicians that APRNs will not locate in rural areas and would not be a solution to primary care shortages in those areas. http://www.nursingworld.org/APRNdistributionreport

Carnevale, A.P., Smith, N., Gulish, A., Beacher, B.H., June, 2012, Healthcare Executive Summary. Georgetown Public Policy Institute, Georgetown University. In this highly informative report on the healthcare workforce it is noted that higher levels of education are increasingly required of the healthcare workforce and that shortages do not exist across the board, rural health and some specialties are disproportionately affected. http://www.georgetown.edu/grad/gppi/hpi/cew/pdfs/Healthcare.ExecutiveSummary.090712.pdf

Liao, C.J., Auraishi, J.A., & Jordan L.M. (2015). Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations. Nursing Economic$ 33(5), 263-270. The authors explore the distribution of anesthesiologists and CRNAs. They note that CRNAs are, more often than anesthesiologists, located in counties with lower median incomes, with higher levels of Medicaid, unemployment, and uninsured. http://www.aana.com/resources2/research/Documents/Liao,%20Quraishi,%20Jordan%20Nursing%20Economics%202015.pdf