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Advanced Practice Nursing: Back to the Future

1997; Elsevier BV; Volume: 26; Issue: 1 Linguagem: Inglês

10.1111/j.1552-6909.1997.tb01512.x

1552-6909

Shannon M. Fitzgerald, Sylvia H. Wood,

Global Health Workforce Issues

Advanced practice nursing has evolved during the last 25 years in important ways to become a central component of the new health care system. The quality of care and cost effectiveness of practice for various advanced practice roles has been well documented. New roles are being created as the demand-driven health care system presents opportunities for innovative practice models. It is incumbent on nursing to prove its ability to assume full accountability and responsibility so that full freedom to practice may be achieved. Advanced practice nursing has evolved during the last 25 years in important ways to become a central component of the new health care system. The quality of care and cost effectiveness of practice for various advanced practice roles has been well documented. New roles are being created as the demand-driven health care system presents opportunities for innovative practice models. It is incumbent on nursing to prove its ability to assume full accountability and responsibility so that full freedom to practice may be achieved. Nursing is poised to become the central unifying component of the United States’ health care delivery system in the 21st century. Major strides toward full use of nursing’s contributions have been made during the last 20 years in the areas of nursing research and in the expansion of recognized advanced practice roles: certified nurse midwives, certified registered nurse anesthetists, clinical nurse specialists and nurse practitioners. Currently numbering more than 100,000, advanced practice nurses provide cost-effective, high quality care in a variety of settings and communities (Brown and Grimes, 1993Brown S.A. Grimes D.E. A meta-analysis of process of care, clinical outcomes, and cost-effectiveness of nurses in primary care roles: Nurse practitioners and certified nurses/midwives. American Nurses Association, Division of Health Policy, Washington, DC1993Google Scholar). As advanced practice nurses set the direction toward the future, we should begin with a reflection on the beginnings of the movement and a description of its status and contributions to the health of the nation. Midwifery was the first role for women in the healing professions; references to midwives appear in the Bible, and the word “obstetrics” is derived from the ancient Greek word for midwife, “obstetrice.” Certified nurse-midwives are a unique specialty in the United States and form a central component of the advanced practice realm. Early in this century, high infant mortality (124 of 1,000 births) in this country was attributed, in part, to unregulated, unlicensed practice by traditional, untrained midwives (Diers, 1992Diers D. Nurse-midwives and nurse anesthetists: The cutting edge in specialist practice.in: Aiken L. Fagin C. Charting nursing’s future: Agenda for the 1990s. J.B. Lippincott Co., Philadelphia1992: 159-180Google Scholar). Through the Sheppard-Towner Act of 1921, funds were provided and state laws were passed to register and standardize the practice of trained midwives. Public health nurses were educated for maternal-child health and worked together with midwives to deliver care to poor, underserved portions of the population. Statistics dramatically improved, with infant mortality decreasing by nearly 40%. However, organized medicine lobbied for the repeal of these nonphysician directed programs, and the funds disappeared in 1929 (Rosen, 1958Rosen G. A history of public health. MD Publications, New York1958Crossref Google Scholar). However, the impact of education and standardization on improved care for maternal-child health had been established during those first 2 decades of this century. Paralleling the evolution of a public health model for maternal-child health, nurse-midwifery emerged in what has been described as “one of the most daring demonstrations of health care ever conceived” (Ernst, 1979Ernst E.K. Tomorrow’s child.Journal of Nurse–Midwifery. 1979; 24: 7-12Crossref PubMed Scopus (1) Google Scholar, p. 7). The founding of Frontier Nursing Service in Hyden, Kentucky, by Mary Breckinridge brought hope to a remote, rural region in Appalachia. Isolated by poverty and geography, and without access to medical care, unacceptably high maternal and infant mortality had become the norm. The impact of the introduction of certified nurse-midwives (CNMs) into this community was quickly recognized. By 1932, a report issued by Metropolitan Life Insurance Company suggested that a drastic reduction in the nation’s perinatal mortality could be appreciated if similar programs were instituted throughout the country (Metropolitan Life Insurance Company, 1932Metropolitan Life Insurance CompanyReport on the first thousand confinements of the Frontier Nursing Service, Inc.Frontier Nursing Service Quarterly Bulletin. 1932, Summer; 8: 9Google Scholar). Continued success by nurse-midwives in improving maternal and infant mortality, from the migrant workers in California and Texas to the women in the inner city projects of New York, brought recognition and support to the profession and the advanced practice of nursing (Montgomery, 1969Montgomery T.A. A case for nurse-midwives.American Journal of Obstetrics and Gynecology. 1969; 105: 309PubMed Scopus (26) Google Scholar, U.S. Congress, Office of Technology Assessment, 1986U.S. Congress, Office of Technology AssessmentNurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. US Government Printing Office, Washington, DC1986Google Scholar). Perhaps, as suggested by Rooks and Fischman, 1980Rooks J. Fischman S. American nurse-midwifery practice in 1976-1977: Reflections of 50 years of growth and development.American Journal of Public Health. 1980; 70: 990-996Crossref PubMed Scopus (14) Google Scholar, these early nurse–midwives “provided a model for the developing concept of nurse practitioners in primary care.” Today there are more than 5,000 certified nurse–midwives in the United States, and their place is firmly fixed in the health care delivery scene. The percentage of births attended by CNMs (5% in this country) has more than doubled during the last decade (American College of Nurse-Midwives (ACNM), 1993American College of Nurse-Midwives (ACNM)Statistics on certified nurse midwives.Journal of Nurse–Midwifery. 1993; 38: 180Google Scholar). The number of midwives and the number of midwife-attended births are projected to double again during the next 5 years if the goals of the ACNM are met. Nurse midwives are still serving the underserved, with 70% of patients seen by CNMs coming from vulnerable populations (American College of Nurse-Midwives (ACNM), 1994American College of Nurse-Midwives (ACNM) Nurse–midwives: Quality care for women and newborns (brochure). Author and American College of Nurse-Midwives Foundation, Washington, DC1994Google Scholar). Although it is legal in all 50 states, the practice of nurse-midwifery, as other advanced nursing practices, is more prevalent where regulations and legislation are more supportive of the practice (Sekscenski et al., 1994Sekscenski E.S. Sansom S. Bazell C. Salmon M.E. Mullan F. State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives.New England Journal of Medicine. 1994; 331: 1266-1271Crossref PubMed Scopus (87) Google Scholar). Preceding the development of professional nurse–midwifery in the United States was the delivery of anesthesia by nurses. Early nurse anesthetists were trained in the late 1800s by the first surgeons in the United States after the discovery of ether, which led to the expanded practice of surgery. Apparently, surgeons initially did not find it necessary for fellow physicians to administer ether and chloroform to their patients, and nurses were heavily used. The Mayo Clinic and other Midwestern hospitals run by the Sisters of the Third Order of St. Francis employed nurses to administer anesthesia from their inception before 1900 (Bankert, 1989Bankert M. Watchful care: A history of America’s nurse anesthetists. Continuum, New York1989Google Scholar). Alice Magaw, the “mother of anesthesia,” was married to Dr. Charles Mayo, participated in the safe administration of anesthesia to thousands of patients before 1900, and published her work extensively (Diers, 1992Diers D. Nurse-midwives and nurse anesthetists: The cutting edge in specialist practice.in: Aiken L. Fagin C. Charting nursing’s future: Agenda for the 1990s. J.B. Lippincott Co., Philadelphia1992: 159-180Google Scholar). The safety and effectiveness of nurse anesthesia has been well documented; nurses provide as much as 70% of the anesthesia care in rural areas of the United States (Bankert, 1989Bankert M. Watchful care: A history of America’s nurse anesthetists. Continuum, New York1989Google Scholar). Certified registered nurse anesthetists (CRNAs) also are employed in urban areas in large tertiary care hospitals. Several landmark court cases have established the rights of CRNAs to practice, on grounds of proven safety to the public, increased consumer choice, and in relation to antitrust laws (Diers, 1992Diers D. Nurse-midwives and nurse anesthetists: The cutting edge in specialist practice.in: Aiken L. Fagin C. Charting nursing’s future: Agenda for the 1990s. J.B. Lippincott Co., Philadelphia1992: 159-180Google Scholar). Numerous rural areas throughout the country would have no anesthesia care available without the help of CRNAs (Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar). Education for CRNAs occurs almost exclusively at the graduate level, and their role as autonomous providers of anesthesia care is well established. The year 1995 marked the 30th anniversary of the development of the nurse practitioner (NP) role as envisioned and created by Loretta Ford, RN, and Henry Silver, MD. Initial planning for the NP role was built on the knowledge and skills of the public health nurse and was in direct response to the need for cost-efficient, easily accessible primary or “first contact” health care in rural, underserved areas (Ford, 1982). Like public health nursing, primary care has been described as coordinated, accessible, continuous, comprehensive, and accountable (Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar). Public health nurses, who have functioned autonomously and from a population-based perspective for most of this century, already were delivering a large component of the direct care. Ford and Silver created another avenue for expert nurses to learn and use skills traditionally reserved for medicine to expand the care they provided. A focus on the medically underserved by NPs helped to lessen competition with physicians during the first few years of their existence. Critical in the development of the NP role was the arrival of funds from the new Medicaid program so that providers providing services to these previously underserved groups and families could begin to be reimbursed (Caraher, 1988Caraher M.T. The importance of third party reimbursement for nurse practitioners.Nurse Practitioner. 1988; 13: 50-54Crossref PubMed Scopus (4) Google Scholar). Early advances in regulatory reform and statutory recognition for NPs were focused exclusively on access to care issues for rural America, and in several states, differentiation exists in terms of practice privileges based on geographic (rural versus urban) location (Intergovernmental Health Policy Project, 1995Intergovernmental Health Policy ProjectScope of practice and reimbursement for advanced practice registered nurses: A state by state analysis. The George Washington University, Washington, D.C.1995Google Scholar). Clinical decision making for NPs generally is a blend of nursing and medical practice; both medical and nursing diagnoses must be made. Because insurance plans generally do not recognize codes for nursing diagnoses, any third party reimbursement gained by NPs is based on medical diagnoses. Although NPs function independently and collaboratively, and as members of interdisciplinary teams, in all settings they retain primary responsibility and accountability for patient care outcomes. The value and worth of primary care as provided by NPs and CNMs is based on clinical studies and research that have resulted in numerous supportive recommendations, policy statements, and congressional testimony during the last 50 years, most of which relate to the lower cost, high quality care provided by advanced practice nurses. However, a recent meta-analysis of studies on nurses in primary care roles reported a decrease in the number of studies conducted during the 1980s from those done in the 1970s (Brown and Grimes, 1993Brown S.A. Grimes D.E. A meta-analysis of process of care, clinical outcomes, and cost-effectiveness of nurses in primary care roles: Nurse practitioners and certified nurses/midwives. American Nurses Association, Division of Health Policy, Washington, DC1993Google Scholar). Existing findings have been consistent, as Brown and Grimes (Brown and Grimes, 1993Brown S.A. Grimes D.E. A meta-analysis of process of care, clinical outcomes, and cost-effectiveness of nurses in primary care roles: Nurse practitioners and certified nurses/midwives. American Nurses Association, Division of Health Policy, Washington, DC1993Google Scholar, p. 31) concluded: For the outcomes that have been measured in the studies included in this meta-analysis, NPs and CNMs had patient outcomes equivalent to or slightly better than those of physicians. Given these outcomes and the lower costs associated with educating and employing NPs and CNMs, it can be concluded that nurses practicing in advanced practice roles are cost-effective providers of primary care. Again and again, studies have shown that NPs deliver care of the same or better quality as that provided by primary care physicians, and patient satisfaction has been well documented (Brush and Capezuti, 1996Brush B.L. Capezuti E.A. Revisiting ‘A nurse for all settings’: The nurse practitioner movement, 1965–1995.Journal of the American Academy of Nurse Practitioners. 1996; 8: 5-11Crossref PubMed Scopus (13) Google Scholar, Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar, U.S. Congress, Office of Technology Assessment, 1986U.S. Congress, Office of Technology AssessmentNurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. US Government Printing Office, Washington, DC1986Google Scholar). The value and worth of primary care as provided by nurse practitioners and nurse–midwives is based on clinical studies and research, which have resulted in numerous supportive recommendations, policy statements, and congressional testimony during the last 50 years, most all of which relate to the lower cost, high-quality care provided by advanced practice nurses. The number of primary care NPs has risen exponentially since 1965; current estimates are that 32,000 NPs are authorized to practice in the United States, and that approximately 12,000 additional nurses are preparing for the role in more than 200 graduate programs (Brush and Capezuti, 1996Brush B.L. Capezuti E.A. Revisiting ‘A nurse for all settings’: The nurse practitioner movement, 1965–1995.Journal of the American Academy of Nurse Practitioners. 1996; 8: 5-11Crossref PubMed Scopus (13) Google Scholar). Roles and the scope of practice have broadened, as can be seen in the transition of the obstetric-gynecologic nurse practitioners into women’s health nurse practitioner programs of study. New roles for NPs are evolving as managed care affects every aspect of the US health care delivery system. Neonatal nurse practitioners (NNPs) were the pioneers of the new acute care and tertiary care practitioner roles. As is the case with all advanced practice roles, NNPs emerged in response to a need to provide more comprehensive, on-site care coordination in neonatal special care units, often those in which neonatologists might not always be physically present or busy units, where more care was required. Practicing collaboradvely with physicians, these nurses use a blend of highly technical, complex skills and advanced clinical decision making. They use medical and nursing diagnoses, and many serve as staff resource leaders, much in the same way clinical nurse specialists function (McGee, 1995McGee D.C. The perinatal nurse practitioner: An innovative model of advanced practice.JOGNN. 1995; 24: 602-606Crossref Scopus (3) Google Scholar). It should be noted that these professionals were called NPs from the onset, as opposed to clinical nurse specialists, which probably is because of their need to write orders, perform procedures independently, and to obtain third party reimbursement. McGee, 1995McGee D.C. The perinatal nurse practitioner: An innovative model of advanced practice.JOGNN. 1995; 24: 602-606Crossref Scopus (3) Google Scholar describes a similar role for perinatal nurse practitioners (PNNPs) in a hospital in Colorado; the role was created specifically to fulfill a need for inpatient NPs when a medical residency ceased to exist in the institution. Education for these PNNPs is a formal, 2-year graduate program; the success of the new program already is evident in terms of patient satisfaction and in the provision of comprehensive, coordinated care. Tertiary nurse practitioner and acute care nurse practitioner programs have developed during the last 5 years to meet a need for specialized care for clients with serious illness. It is hoped that collaborative structures for these new types of NP practice, with NPs retaining full accountability for the care they provide, will reduce costs through the creation of new ways of providing care (Harshman Green and Conway-Welch, 1995Harshman Green A. Conway-Welch C. Integrated health care and the advanced practice nurse. Aspen Publishers, inc., Gaithersburg, MD1995: 42-80Google Scholar). Specialization in acute nursing care has probably always existed, but a critical need to provide expert, technically complex nursing care arose in the 1960s, when a general nursing shortage existed at the same time that technology in health care was exploding (Hamric and Taylor, 1989Hamric A.B. Taylor J.W. Role development of the clinical nurse specialist.in: Hamric A.B. Spross J.A. The clinical nurse specialist in theory and practice. 2nd ed. W.B. Saunders Co., Philadelphia1989: 3-18Google Scholar). Clinical nurse specialists (CNSs) became the supernurses at the bedside, the resource people for patient care teams, and the developers and leaders of clinical scholarship and expertise in complex nursing care. According to statistics, 58,000 CNSs have been prepared at the graduate level, but as is true with all segments of advanced practice, it is difficult to ascertain how many are employed in the role (De Angelis, 1994De Angelis C.D. Nurse practitioner redux.Journal of the American Medical Association. 1994; 271: 868-871Crossref Scopus (41) Google Scholar). As health care delivery has moved into community settings in the 1990s, some CNSs have moved to home care, subacute care settings, and clinics. Clinical nurse specialists are prepared at the graduate level, exercise independent clinical decision making, and usually use nursing diagnoses. Because their salaries traditionally have been included as part of the overall institutional nursing budget, they have not independently billed third party insurance companies for services and in most states do not possess second licenses or prescriptive authority (Intergovernmental Health Policy Project, 1995Intergovernmental Health Policy ProjectScope of practice and reimbursement for advanced practice registered nurses: A state by state analysis. The George Washington University, Washington, D.C.1995Google Scholar). Usually, CNSs are not the patient’s first contact with the health care system (as are primary care NPs), and there generally is a physician retaining ultimate responsibility for patient care outcomes (Page and Arena, 1994Page N.E. Arena D.M. Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles.Image. 1994; 26: 315-318Google Scholar). In some practice settings, CNSs function primarily as staff resource leaders, but their knowledge and skills clearly are imbedded in expert nursing practice, and they provide a critical link in the delivery of continuous care to patients (Hamric and Taylor, 1989Hamric A.B. Taylor J.W. Role development of the clinical nurse specialist.in: Hamric A.B. Spross J.A. The clinical nurse specialist in theory and practice. 2nd ed. W.B. Saunders Co., Philadelphia1989: 3-18Google Scholar). Dramatic changes accompanying the vertical integration of health care systems have affected the employment of CNSs by acute care institutions. One reason for this may be that they are not directly billing for services provided or are not seen as contractors in networks when managed care contracts are created (Harshman Green and Conway-Welch, 1995Harshman Green A. Conway-Welch C. Integrated health care and the advanced practice nurse. Aspen Publishers, inc., Gaithersburg, MD1995: 42-80Google Scholar). Nurse practitioners have been more successful than CNS in gaining prescriptive authority and direct third party reimbursement, and there is greater public recognition for the term NP than for that of CNS (Page and Arena, 1994Page N.E. Arena D.M. Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles.Image. 1994; 26: 315-318Google Scholar). Because of their invisibility within nursing budgets and staffing structures, less evidence exists to prove that the role of the traditional inpatient role of the CNS is cost effective than exists for primary care NPs, CRNAs, and CNMs. However, the roles of CNSs are unique and valuable, and they clearly have never been seen as physician substitutes; most studies of NPs, CNMs, and CRNAs have compared their work with that of physicians (Brown and Grimes, 1993Brown S.A. Grimes D.E. A meta-analysis of process of care, clinical outcomes, and cost-effectiveness of nurses in primary care roles: Nurse practitioners and certified nurses/midwives. American Nurses Association, Division of Health Policy, Washington, DC1993Google Scholar). It is clear that new ways of evaluating practice effectiveness must be developed. In some markets, hospital based NPs or in some settings CNSs are beginning to replace or augment medical house staff, and in this role, they assume primary responsibility for patient care, are recognized by medical center credentialing committees, have gained prescriptive authority, and are involved at some level with third party reimbursement for services provided in the hospitals, clinics, and other settings (Brooten et al., 1986Brooten D. Kumar S. Brown L.P. Butts P. Finkler S.A. Bakewell S.S. Gibbons A. Delivoria-Papadopoulos M. A randomized clinical trial of early hospital discharge and home follow-up of very low birth weight infants.New England Journal of Medicine. 1986; 315: 934-939Crossref PubMed Scopus (337) Google Scholar, Edmunds and Ruth, 1991Edmunds M.W. Ruth M.W. Nps who replace physicians: Role expansion or exploitation?.Nurse Practitioner. 1991; 16: 46-49Crossref PubMed Google Scholar, McGee, 1995McGee D.C. The perinatal nurse practitioner: An innovative model of advanced practice.JOGNN. 1995; 24: 602-606Crossref Scopus (3) Google Scholar). Whether they are NPS or CNSs, the need for this role has been documented in several sources (Harshman Green and Conway-Welch, 1995Harshman Green A. Conway-Welch C. Integrated health care and the advanced practice nurse. Aspen Publishers, inc., Gaithersburg, MD1995: 42-80Google Scholar, Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar). If the number of medical residencies is reduced, as recommended by the Pew Commission (Finocchio et al., 1995Finocchio L.J. Dower C.M. Mcmahon T. Gragnola C.M. The Taskforce on Health Care Workforce Regulation Reforming health care workforce regulation: Policy considerations for the 21st century. Pew Health Professions Commission, San Francisco, CA1995Google Scholar), the need for nursing specialists may rise (McGee, 1995McGee D.C. The perinatal nurse practitioner: An innovative model of advanced practice.JOGNN. 1995; 24: 602-606Crossref Scopus (3) Google Scholar). In addition, the trend of shorter hospital stays with increasingly ill clients is likely to escalate and persist, leading to a need for nurses with increasingly advanced skills to lead teams of less-educated care providers (Keane and Richmond, 1993Keane A. Richmond T. Tertiary nurse practitioners.Image: Journal of Nursing Scholarship. 1993; 25: 281-284Crossref PubMed Scopus (34) Google Scholar). Most forms of education for advanced practice began as short didactic curricula and apprenticeship learning within clinical institutions and agencies. Nurse practitioner and nurse midwifery programs initially were certificate programs; CNSs grew into their roles because they were natural clinical leaders and experts and were the first to establish a master’s degree as the entry level of education (Hawkins and Thibodeau, 1993Hawkins J.W. Thibodeau J.A. The advanced practitioner: Current practice issues. 3rd ed. The Tiresias Press, New York1993Google Scholar). Christman, 1992Christman L. Advanced nursing practice: Future of clinical nurse specialists.in: Aiken L. Fagin C. Charting nursing’s future: Agenda for the 1990s. J.B. Lippincott Co., Philadelphia1992: 108-120Google Scholar notes that entry to the practices of nutrition and physical therapy has been at the graduate level for decades and that nursing has experienced a lag in the move toward higher educational levels for practice. As of 1996, most educational programs for advanced practice are at the graduate level in an effort to standardize curricula and to guarantee a minimum level of education. Christman estimates that 6% of the nation’s corps of nurses are involved in independent advance practice. For nursing to fully contribute to the health care delivery teams of the future, many more nurses must prepare themselves educationally and clinically for advanced roles. The American College of Nurse-Midwives and the American Association of Nurse Anesthetists accredit their own educational programs. The National League for Nursing accredits master’s programs that house the nurse practitioner programs, but no separate accrediting system exists for nurse practitioner curricula. Task forces of the National Organization of Nurse Practitioner Faculties, the American Association of Colleges of Nursing, the National League for Nursing, and other groups are working on collaborative methods to accomplish this goal, which will serve as a guide for legislators, educators, and regulators. Perhaps the increased job satisfaction that is associated with autonomous roles (Schutzenhofer and Musser, 1994Schutzenhofer K.K. Musser D.M. Nurse characteristics and professional autonomy.Image. 1994; 26: 201-205Google Scholar) and contribution to quality care will draw more and more of these nurses into higher degree programs and allow nursing to make a large impact on the quality of care delivered. It is time to recognize and celebrate clinical leadership and clinical education in nursing and to facilitate clinical achievement and advanced practice roles for more nurses. It is critical that consistent standards for graduate education be applied in all advanced practice areas and that innovative methods for advancing to nursing at the graduate level be introduced so that a greater number of nurses can move into graduate programs. Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar, by profession an attorney, describes the array of initials and titles used to identify advanced practice nurses as “the rubble from the Tower of Babel.” The Pew Commission’s Task Force on Health Care Workforce Regulation (Finocchio et al., 1995Finocchio L.J. Dower C.M. Mcmahon T. Gragnola C.M. The Taskforce on Health Care Workforce Regulation Reforming health care workforce regulation: Policy considerations for the 21st century. Pew Health Professions Commission, San Francisco, CA1995Google Scholar) has identified the confusion surrounding entry to practice for advanced practice nurses as a major barrier for mobility of health care professionals and for increasing the supply of available practitioners to meet primary health care needs. For instance, no common definition of NP exists among the 50 states, and educational standards vary widely in regulatory language. Curricular standards and accrediting systems have been developed by the professional organizations for nurse-midwives and nurse anesthetists. National certification adds to the credentialing process and increases credibility with the public and third-party payers. Interestingly, new roles are incorporating NP (acute care NP, perinatal NP) as opposed to CNS. Certification is not required for licensure for advanced practice in all states, and there are some questions about which, if any, professional organizations should provide the mechanisms for certification. Certified nurse midwives and CRNAs probably have the most consistency regarding type of practice, initials used, and certification and educational standards because of their long history of self-governance and internal standards. As many as 19 different initials for NPs have been counted by these authors, with more on the way as new programs develop. Recognition for the valuable work done by CNSs is virtually absent from all state statutes (Intergovernmental Health Policy Project, 1995Intergovernmental Health Policy ProjectScope of practice and reimbursement for advanced practice registered nurses: A state by state analysis. The George Washington University, Washington, D.C.1995Google Scholar). These authors would like to propose that fewer sets of initials be used to identify advanced practice nurses, with the goal that the public, state legislators, and the insurance industry will be able to more easily recognize and validate the worth of the practice of such nurses. Certified nurse midwives and CRNAs have been self-accrediting, clearly defined subsets of the advanced practice realm for years; their initials should remain CNM and CRNA in all states. “NP” is a recognized title in most parts of the country; our proposal is that efforts be coordinated to allow CNSs whose continued or post-master’s education matches the key components of the NP role (pharmacology, advanced assessment, independent clinical management, role components) to bridge into NP licensure and recognition (Forbes et al., 1990Forbes K.E. Rafson J. Spross J.A. Koslowski I. The clinical nurse specialist and the nurse practitioner: Core curriculum survey results.Clinical Nurse Specialist. 1990; 4: 63-66Crossref PubMed Google Scholar). We believe these three sets of initials (NP, CNM, CRNA) would be less confusing to the public, legislators, and reimbursement networks than the creation of a totally new set of initials, such as APN (advanced practice nurse). Nursing does not need another public relations dilemma and challenge. Deletion of well-recognized titles (CNM, NP, CRNA) would serve to decrease nursing’s visibility as independent providers. Nurse practice laws traditionally are seen as “carve-outs” from the broad medical practice acts. However, midwifery, along with care of the ill by family members, often is excluded from the statutes that define medical practice because the practice of nurse-midwifery predates the practice of medical obstetrics in this country. The statutory language for the other categories of advanced practice nursing usually is much less clear. Exhaustive surveys of the regulatory environments in the states have revealed little consistency among requirements for licensure, entry to practice standards, prescriptive authority, freedom from physician supervision, and third party reimbursement (Intergovernmental Health Policy Project, 1995Intergovernmental Health Policy ProjectScope of practice and reimbursement for advanced practice registered nurses: A state by state analysis. The George Washington University, Washington, D.C.1995Google Scholar, Sekscenski et al., 1994Sekscenski E.S. Sansom S. Bazell C. Salmon M.E. Mullan F. State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives.New England Journal of Medicine. 1994; 331: 1266-1271Crossref PubMed Scopus (87) Google Scholar). Efforts to gain prescriptive authority, independent practice, and third party reimbursement for NPs have been more likely to be successful in states with large, rural underserved populations (for example, New Mexico and Alaska) than in urban, physician-dense states, such as Illinois and Ohio (Intergovernmental Health Policy Project, 1995Intergovernmental Health Policy ProjectScope of practice and reimbursement for advanced practice registered nurses: A state by state analysis. The George Washington University, Washington, D.C.1995Google Scholar). Clarity regarding regulatory agencies and the use of advanced practice nurses exists in only one domain. When favorable practice environments exist, including freedom from physician supervision, prescriptive authority, and the ability to be reimbursed for services provided, the number of NPs, nurse–midwives, and other nonphysician providers increases for residents of individual states (Sekscenski et al., 1994Sekscenski E.S. Sansom S. Bazell C. Salmon M.E. Mullan F. State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives.New England Journal of Medicine. 1994; 331: 1266-1271Crossref PubMed Scopus (87) Google Scholar). One can only conclude that if you build it, they will come. Nursing has struggled with its own identity as a profession since its inception. We believe it is time to end that debate and to recognize that for any profession to advance, complete accountability for practice and the autonomy of its practitioners must be evident. The American College of Nurse-Midwives (ACNM), 1995American College of Nurse-Midwives (ACNM)Clinical practice guideline, clinical practice committee.Journal of Nurse-Midwifery. 1995; 40: 58Google Scholar recently released a clinical practice statement addressing collaboration, independence, and professionalism that we would like to recommend be applied to all of the levels and varieties of advanced practice nursing: Independent Nurse-Midwifery PracticeIt is the position of the American College of Nurse-Midwives (ACNM) that nurse-midwifery practice is the independent management of women’s health care, focusing particularly on pregnancy, childbirth, the postpartum period, care of the newborn and the family planning and gynecologic needs of women. This practice occurs within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client.Independent nurse-midwifery practice enables certified nurse-midwives (CNMs) to utilize knowledge, skills, judgement, and authority in the provision of primary women’s health services while maintaining accountability for the management of patient care in accordance with the ACNM Standards for the Practice of Nurse–Midwifery.The ACNM believes that independent practice is not defined by the place of employment, the employee-employer relationship, requirements for physician co-signature, or the method of reimbursement for services. Nor should independent be interpreted to mean alone, as there are clinical situations when any prudent practitioner would seek the assistance of another qualified practitioner.The ACNM also believes that collaboration is the process whereby health care professionals jointly manage care. The goal of collaboration is to share authority while providing quality care within each individual’s professional scope of practice. Successful collaboration is a way of thinking and relating that requires knowledge, open communication, mutual respect, a commitment to providing quality care, trust, and the ability to share responsibility. The ACNM position need only be adapted to different clinical arenas, varying patient groups, and the myriad of valuable clinical specialties for advanced practitioners of nursing. If such a position were taken by all involved, the consistent introspection of our own field would cease, and we could assume our position at the table as the central component of the emerging health care system. In her landmark article, Safriet, 1992Safriet B.J. Health care dollars and regulatory sense: The role of advanced practice nursing.Yale Journal of Regulation. 1992; 9: 417-488Google Scholar proposes that continued lifting of restrictions on the practice of NPs and CNMs would not solve all of the problems related to the cost of care delivery but would do much to increase the ease of access for affected individuals and families. Nursing has struggled with its identity as a profession since its inception. We believe it is time to end that debate and to recognize that for any profession to advance, complete accountability for practice and the autonomy of its practitioners must be evident. As health care professionals in the new world of health care, we have been challenged to redesign, re-regulate, right size, and restructure toward a demand-driven system (Finocchio et al., 1995Finocchio L.J. Dower C.M. Mcmahon T. Gragnola C.M. The Taskforce on Health Care Workforce Regulation Reforming health care workforce regulation: Policy considerations for the 21st century. Pew Health Professions Commission, San Francisco, CA1995Google Scholar). As advanced practice nurses we should welcome these challenges, which so closely resemble the goals of our practice. We must continue to strive to increase access to health care, to eliminate restrictions of practice to qualified providers, to ensure the patients’ rights to choose their providers, and to provide quality, cost-effective care. As we enter the next millennium, we must recognize and realize the potential of our profession on the health care of our future.