1. Randy Fink Frontier Nursing University December 5 th, 2012

2.  A Registered Nurse trained in one of four advanced practice roles at the graduate level (National Council of State Boards of Nursing, 2008)

3.  Certified Nurse Practitioner  Clinical Nurse Specialist  Certified Nurse-Midwife  Certified Registered Nurse Anesthetist

4.  Anesthesia care through the lifespan  Surgery  Obstetrics  outpatient (American Association of Nurse Anesthetists [AANA], 2012a)

5. BSN 1 year critical care experience graduate from accredited CRNA school with minimum MSN and pass national certification (AANA, 2012a) 112 CRNA programs nationwide 9 programs in Florida (Best Nursing Degree, 2012a) 3500 CRNAs in Florida (Florida Association of Nurse Anesthetists, 2012 )

6.  Primary healthcare to women  Physical exams  Prescriptions  Laboratory testing  Gynecological care  Labor, birth, and prenatal care  Counseling and health education (American College of Nurse-Midwives [ACNM], 2012a)

7.  Birth centers  Hospitals  Outpatient  Homes (ACNM, 2012b)

8.  RN  Graduate level CNM program  National certification (ACNM, 2012c)  38 CNM programs nationwide  2 programs in Florida (Best Nursing Degree, 2012b)  722 Florida CNMs (Florida Department of Health [FDOH], 2012)

9.  Specialized care for: ◦ Population ◦ Setting ◦ Type of care, problem or disease (National Association of Clinical Nurse Specialists [NACNS],2012)

10.  RN  MSN or Doctoral  Advanced Clinical Training  Specialization certification (NACNS, 2012)  193 CNS nationwide  4 programs in Florida (Best Nursing Degree, 2012c)  272 CNS in Florida ◦ Divided into 8 specialties:  Adult, pediatric, adult health, medsurg, gerontology, adult mental health, child mental health, community health (FDOH, 2012)

11.  Primary, preventive, chronic, acute, or specialty care  Autonomously or in collaboration  Outpatient ◦ Office, clinic, retail  Inpatient (American Academy of Nurse Practitioners [AANP], 2012)  Numbers ◦ 180, 233 Nurse Practitioners ◦ 12, 677 Florida NPs (Pearson Report, 2012)

12.  Order and interpret x-rays  Order and interpret diagnostic labs  Prescribe medications and treatments  Patient education and counseling  Manage chronic and acute conditions  Utilize Nursing Process (ADPIE): ◦ Assess ◦ Diagnose ◦ Plan ◦ Implement ◦ Evaluate (AANP, 2012)

13.  Family Health  Sub-specialties (systems) (AANP, 2012) Acute healthAdult Health GerontologyNeonatal OncologyPediatric PsychiatricWomen’s Health

14.  RN  MSN or Doctorate  Certification/specialty (AANP, 2012)  Over 350 universities nationwide ◦ 850 different program tracks  15 programs in Florida (Best Nursing Degree, 2012d)

15.  Each state defines ◦ Scope ◦ Roles ◦ Prescriptive authority  19 states no physician required  32 states require physician involvement (Pearson Report, 2012) ◦ Diagnosis and treatment  27 states no physician involvement  24 states require physician involvement (Pearson Report, 2012)

16.  Joint regulations: ◦ Board of Nursing/Board of Medicine ◦ Physician involvement required  Written agreement between:  MD, DO, DDS (FDOH, 2007)

17.  NP Functions: ◦ History and physicals ◦ Diagnostic studies ◦ Well care ◦ Preventive care ◦ Patient Education ◦ Drug therapies ◦ Medical treatments ◦ Minor procedures (FDOH, 2007)

18. CRNA Civil War 1909 1 st program in Portland, OR 1931 1 st national organization Principal anesthesia providers in military (AANA, 2012b)

19.  CNS ◦ Early 20 th century ◦ Push for curriculum standards ◦ 1950s psychiatric clinical specialist ◦ Today CNS highly specialized (Fulton, Lyon, & Goudreau, 2012)

20.  CNM ◦ Early colonists ◦ 1920s nurse midwifery profession  High infant and maternal mortality ◦ 1920s Mary Breckenridge Frontier Nursing Service  1939 Frontier Graduate School of Midwifery (My Midwife, 2012)

21.  CNP ◦ 1965 1 st NP program in Colorado ◦ 1973 65 NP programs ◦ 1985 AANP established  Increased standardization (AANP, 2012)

22.  Legislative ◦ Medicare reimbursement 1990 (rural areas) ◦ Balanced Budget Act 1997 (all locations) (Medicare Payment Advisory Commission, 2002) ◦ Affordable Care Act  Then and Now ◦ 1960s: birth of CNP ◦ Today: CNS mainstream care  CNPs found in ½ primary care offices (U.S. Department of Health And Human Services, 2011)

23.  Occupational Health Clinic ◦ Convenience Sample  Patient Satisfaction = 89.1% (Guzik, Menzel, Fitzpatrick, & McNulty, 2009)

24.  Systematic literature review = 1990-2008 ◦ CNP/CNM/CNS  Outcomes and quality = or> than MD (Newhouse et al., 2011)

25. American Academy of Nurse Practitioners (2012). What's an NP? Retrieved from http://www.aanp.org American Association of Nurse Anesthetists (2012a). Become a CRNA. Retrieved from http://aana.com American Association of Nurse Anesthetists (2012b). History of nurse anesthesia practice. Retrieved from http://aana.com American College of Nurse-Midwives (2012a). About midwives. Retrieved from http://www.midwife.org American College of Nurse-Midwives (2012b). Definition of midwifery and scope of practice of certified nurse-midwives and certified midwives. Retrieved from http://www.midwife.org College of Nurse-Midwives (2012c). Become a Midwife. Retrieved from http://www.midwife.org Best Nursing Degree (2012a). Certified registered nurse anesthetist programs. Retrieved from http://www.bestnursingdegree.com Best Nursing Degree (2012b). Nurse-midwife programs. Retrieved November 8, 2012, from http://www.bestnursingdegree.com Best Nursing Degree (2012c). Clinical nurse specialist degree programs. Retrieved from http://www.bestnursingdegree.com Best Nursing Degree (2012d). Nurse practitioner programs. Retrieved from http://www.bestnursingdegree.com Florida Association of Nurse Anesthetists (2012). FANA home. Retrieved from http://www.fana.org/default.asp Florida Department of Health (2007). Nurse practice act. Retrieved from http://www.doh.state.fl.us/mqa/nursing/info_practiceAct.pdf

26. Florida Department of Health (2012). Search for practitioner profile information. Retrieved from http://ww2.doh.state.fl.us/IRM00profiling/searchform.ASP Fulton, J., Lyon, B., & Goudreau, K. (Eds.). (2012). Foundations of clinical nurse specialist Practice (1st ed.). New York: Springer. Guzik, A., Menzel, N., Fitzpatrick, J., & McNulty, R. (2009). Patient satisfaction with nurse practitioner and physician services in the occupational health setting. American Association of Occupational Health Nurses, 57(5), 191-197. doi:10.9999/08910162-20090428-06 Medicare Payment Advisory Commission (2002). Report to the Congress: Medicare payment to advanced practice nurses and physician assistants. Retrieved from http://www.medpac.gov/documents/jun02_NonPhysPay.pdf My Midwife (2012). A brief history of nurse-midwifery in the U.S. Retrieved from http://www.mymidwife.org National Association of Clinical Nurse Specialists (2012). CNS FAQs: What is a clinical nurse specialist. Retrieved from http://www.nacns.org Newhouse, R., Stanik-Hutt, J., White, K., Johantgen, M., Bass, E., Zangaro, G.,...Weiner, J. (2011). Advanced practice nurse outcomes. Nursing Economics, 29(5), 230-250. Retrieved from https://www.nursingeconomics.net/ce/2013/article3001021.pdf Pearson Report (2012). Florida. Retrieved from http://www.pearsonreport.com U.S. Department of Health and Human Services (2011). Nurse practitioners, certified nurse midwives, and physician assistants in physician offices (NCHS Data Brief: No. 69). Washington, DC: U.S. Government Printing Office.

27. Contact information: Randy Fink randy.fink@frontier.edu