place in an almost infinite variety of settings, ranging from the intensive care unit of trauma centers to schools, patients’ homes, prisons, longterm care facilities and nursing homes, community health clinics, and outreach centers. While these diffuse practice settings and roles have no doubt enhanced the nation’s health, the very diffusion and multifaceted nature of nursing practice has often meant that nursing has been slighted in the nascent measurement movement which seeks to apply cost and care-effectiveness standards.

  1. Economic invisibility. Nursing services traditionally have been treated as an expense (albeit an essential one) rather than as an individually identified revenue or income source on institutional or governmental balance sheets. And from the patient’s perspective, nursing services rarely, if ever, are separated out from institutional room charges or other professional fees on billing statements. Unsurprisingly, these accounting practices promote the widespread perception that nurses are not “revenue generators” (RWJF, 2010). Perhaps in part because of this “revenue invisibility,” nursing has been underrepresented in, or excluded from, the decision-making processes (both private and governmental) that determine the metrics upon which costs, value, pricing, and payment are based. This asymmetrical financial treatment has special salience today, as most reform proposals are focused increasingly on defining the value of services and rewarding the attainment of performance measures. And as APNs continue to participate in, and often lead, the development of innovative practice models designed to better meet patients’ needs, it is essential that payment schemes include complete and accurate measurement and valuation of their services.

  2. Multiple routes of entry. Nursing is the only profession which has multiple educational pathways leading to professional licensure. In all states but one, successful completion of 2-, 3- and 4-year degree programs is recognized as fulfilling the educational requirements for licensure as a registered nurse (RN). This unique multiplicity of qualifying pathways is supported by some, and opposed by others, in the professional, educational, and policy-making arenas, and it will no doubt continue to be assessed as workforce policy focuses on ensuring an adequate supply of well-prepared nurses. Regardless of how this issue is ultimately addressed, however, the current reality is that 2 years of nursing education meets the educational requirement for licensure as a registered nurse, which is the first step for recognition and licensure as an APN. This fact has posed problems for those who seek to promote wider legal authority for, and utilization of, APNs. Even though master’s-level education and national certification are now uniformly required for APN licensure,5

5

For a recently adopted uniform framework for APNs, see APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee (2008).



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