of practice for NPs is particularly important for the rural and frontier areas of the country. Twenty-five percent of the U.S. population lives in these areas; however, only 10 percent of physicians practice in these areas (NRHA, 2010). People who live in rural areas are generally poorer and have higher morbidity and mortality rates than their counterparts in suburban and urban settings, and they are in need of a reliable source of primary care providers (NRHA, 2010). The case study in Box 3-2, describing an NP in rural Iowa, demonstrates the benefits of a broad scope of practice with respect to the quality of and access to care.

Scope of Practice for Non-APRN Nurses

Generalist nurses are expanding their practices across all settings to meet the needs of patients. Expansions include procedure-based skills (involving, for example, IVs and cardiac outputs), as well as clinical judgment skills (e.g., taking health histories and performing physical examinations to develop a plan of nursing care). According to Djukic and Kovner (2010), there has been “no formal examination of the impact of RN role expansion on care cost or on physician and RN workload.” The authors describe the expansion as a shifting of skills and activities, which in the long run, given the physician shortage, could free up physician resources, especially in long-term care, community health, and school-based health. On the other hand, given the projected nursing shortage, task shifting to overworked nurses could create unsafe patient care environments, especially in acute care hospitals. To avert this situation, nurses need to delegate to others, such as LPNs, nursing assistants, and community health workers, among others. A transformed nursing education system that is able to respond to changes in science and contextual factors, such as population demographics, will be able to incorporate needed new skills and support full scopes of practice for non-APRNs to meet the needs of patients (see Chapter 4).

Professional Resistance

Increasing access to care by expanding state scope-of-practice regulations so they accord with the education and competency of APRNs is a critical and controversial topic. Practice boundaries are constantly changing with the emergence of new technologies, evolving patient expectations, and workforce issues. Yet the movement to expand scopes of practice is not supported by some professional medical organizations. Professional tensions surrounding practice boundaries are not limited to nurses and physicians, but show a certain continuity across many disciplines. Psychiatrists and psychologists have been disagreeing about prescriptive privileges for more than two decades (Daly, 2007). In the dental field, one new role, the advanced dental hygiene practitioner, functions under a broadened scope similar to that of an APRN. The American Dental Association does not



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