Analysis of Advanced Practice Nurse Roles and Issues

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became widely available throughout the United States. At this time clinical doctoral programs were created and the beginning of the nurse practitioner and clinical nurse specialist movement occurred. Advanced practice nursing roles and the level of their expertise will be critical as the nation focuses on improving patient care and the safety with a system that uses ancillary services to deliver health care. (p. 33)

The authors concluded, “Nursing is the most comprehensive of all health care professions and carries the demands of understanding the human condition, client environment, system of care delivery, and political milieu of care” (DeNisco & Barker, 2012, p 35).

Identifying Issues and Challenges

The history of the development of the APN role shows there have been roadblocks and issues along the way for the APN. According to Shi and Singh (2012),

Some other issues the APN could have are related to health care and health care policies, especially since the United States has no centrally controlled system of health care, and a lot of decisions related to health care are made by people who are not in the industry. The conflict between market and social justice is reflected throughout US health care delivery. The health care status of a population has a tremendous bearing on the utilization of health services. Assuming that the services are readily available, planning of health services must be governed by demographic and health trends and initiatives toward reducing disease and disability. (p. 38)

Potential Benefits, Challenges, and Limitations for Advanced Practice Nursing Roles

Shi and Singh (2012) defined health policy as “the aggregate of principles, stated or unstated, that characterize the distribution of resources, services, and political influences that impact the health of the population, and Health policies can be made through the private sector or the public policymaking process” (p. 535). An example of a private sector health policy is insurance company decisions regarding their product lines, pricing, and marketing (Shi & Singh, 2012). Shi and Singh (2012) warned:

The focus of the private sector is on restricting the public policymaking process and the results from these processes, such as: major reforms in medical education, Medicare and Medicaid programs, federally funded family planning clinics, courts decisions that the merger of two hospitals violates federal antitrust laws, a state government’s decisions about its procedures for licensing physicians, a county health department’s decisions about its procedures for monitoring sanitation standards in restaurants, and a city government’s enactment of an ordinance banning smoking in public places. Thus health policies can take several different forms. (p. 535)

The Accountable Care Act (ACA) is another health policy issue that may have consequences for APNs. Zall and Mills (2011) described one such issue related to nursing services for seniors:

[In] the U.S. Department of Health & Human Services’ Centers for Medicare & Medicaid Services (CMS) models of bundling Medicare payments through the Bundled Payments for Care Improvement Initiative. . . bundled payment, or episode-based payment, reimburses multiple providers (hospitals, physicians, and post-acute care) in a single, comprehensive payment that covers all of the services involved in the patient’s care. An episode can take many forms, from a single rate for all services relating to a particular procedure, combining hospital care and post-acute care, to all treatment associated with a chronic condition for a defined period of time. (p. 1)

Barriers to Advanced Practicing Nursing Within the Nursing Profession and Healthcare System

The ACA could cause problems for the health industry and the APN. Kind et al. (2014) reported:

Some reports show physicians reducing the amount of laboratory exams and diagnostic procedures deemed necessary and discharges for patients occurring sooner than patient expectations. Thirty day re-hospitalization affects 1 in 5 hospitalized Medicare patients, costs more than $17 billion annually and results in hospital-based Medicare payment penalties for congestive heart failure, pneumonia, and acute myocardial infarction re-hospitalization. (p. 765)

Further, Burns et al. (2014) reported that the ACA expanded eligibility for Medicaid to include “adults below the 138 percent of the Federal Poverty Level, as well as two-thirds of the eligible adult population are without dependent children” (p. 2173). Burns et al. (2014) conducted a study and found enactment of the ACA led to “an increase in inpatient stays . . . [no] effect on emergency department visits, and an increase in outpatient visits” (p. 2174). The increases in both inpatient stays and outpatient visits could cause major concerns problems for the APN dealing with patients and ensuring, as they do, that their patients get the best possible care, regardless of payment. Mariner (2014) stated:

The Affordable Care Act is intended to provide near-universal health insurance coverage that seeks greater consistency in health insurance coverage by regulating the terms of most plans and regulating commercial practices of private insurers. Some of the requirements of the Affordable Care Act resemble product standards in a product conception of insurance and is regulating the health insurance industry like a modern public utility. (p. 195)

In light of the social context of the APN, it is worth noting that “nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (American Nurses Association [ANA], 2010, p. 8). Some of the social concerns for the APN are in health care, and nursing health care continues to be a major focus of attention in the United States and worldwide. According to the ANA, “Many other societal concerns garner extensive attention and subsequent action by the nursing profession and its nurse constituency” (p. 8).

Nursing has an active and enduring leadership role in public and political determinations about the following six key areas of health care, which were taken from the ANA (2010):

• Organization, delivery, and financing of quality health care

Quality health care is a human right for all (ANA, 2010). To improve the quality of care, healthcare professionals must address these complex issues: increasing costs of care; health disparities; and the lack of safe, accessible, and available healthcare

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