discussed by all of the participants. The most “preferred strategies” by participants were face-to-face meetings (APRN leaders with both physician opponents and legislators), grassroots actions by individual APRN constituents, and presentation of evidence,
including how the Consensus Model will benefit patients, and studies pertaining to the quality and cost-effectiveness of APRN healthcare services.
While participants discussed different Model attractors or facilitators (APRNs, physicians, the AARP), most implementation strategies revolved around APRN
leadership activities. While participants reported that support from the Board of Nursing was critical, the Board alone was not capable of implementing change. Action from individual APRN leaders or leadership groups, like the Advanced Practice Committee (APC) was found to be crucial, especially “active” strategies, like face-to-face meetings with other stakeholders, including physicians and legislators. One participant described the importance of keeping physician-opponents informed:
Personally, I think physicians…that’s my main target. I think face-to-face meetings. We’ve [APRN leaders] got to get on face-to-face ground with them.
…What they [legislators] recommended we [APRN leaders] do is get more physician support behind us so that when we do get the bill introduced, it does go through smoothly.
Another participant discussed APRN leader face-to-face lobbying of legislators:
I think we [APRN leaders] need to keep talking to the legislators…We’ve got to keep the Consensus Model in their brains so that when it [Model bill] does get introduced, they are familiar with it. I just don’t think we can stop. I think it’s vitally important.
Grassroots activities, including APRN leaders encouraging individual APRN clinicians to meet with legislators face-to-face, were regularly identified as instrumental
Model strategies. However, the importance of having the APRN be a constituent of the legislator was stressed. The effectiveness of face-to-face interaction with legislators diminished when the APRN was not a constituent, or the interaction took place at a fundraiser or reception, rather than in the legislator state office, as captured by one participant:
With constituents…that legislator sees you as a vote. …[With fundraisers], that’s definitely different than having a constituent [talk one-on-one]. I guess it’s effective, but it almost seems kind of unethical in a way. It’s like buying their vote…but that’s the reality, I know.
The effectiveness and variety of different APRN grassroots efforts were described by one participant:
I think our best bet [to implement the Model] is to push grassroots efforts as much as possible. …I have a nurse practitioner colleague…as she always says to her colleagues, “Give me your time, talent, or treasure.” “If you don’t have treasure to give, then give me your time or your talent.” Talent can take a variety of different forms. It may be things like you have a connection with a particular legislator.
The presentation of evidence, including facts pertaining to how Consensus Model implementation would benefits patients, was recommended by all participants.
Participants reported that both written communications and verbal messaging must be clear and concise, with a primary focus on the benefits for Delawareans. Individual patient stories were deemed to be especially effective when presented to policymakers.
Unfortunately, with the introduction of a lot of [healthcare] legislation, very rarely does it even mention the role of the patients. I think that’s a powerful tool that APRNs could use to really bring the conversation full circle. …You have to have the data in and around the issue. For example, the lack of access to care, and the quality of APRN practice. The numbers of APRNs, the safety of the practice. That data needs to be a key piece…but the other piece has to be the patient’s story.
…The “Triple Aim”…reducing costs, improving health outcomes, and [improving] patient access to care.
Table 3
Delaware Case Study APRN Consensus Model Implementation Major Themes and Subthemes
Subtheme 1: Model Opposition Subtheme 1: Model Facilitators Subtheme 2: Deficient Consensus Model
Four Maryland participants were interviewed, including one individual
representing nursing regulation, one APRN clinician, one APRN educator, and a lobbyist conversant with APRN practice and healthcare legislation. The representative from
nursing regulation, doctorally-prepared, has been employed in nursing regulation for more than 10 years. The APRN clinician, also doctorally-prepared, currently serves in multiple nursing leadership positions and has authored and co-authored multiple
publications in peer-reviewed journals addressing advanced practice nursing quality and practice topics. The APRN educator, possessing a master’s degree, has been both a clinician and educator in a graduate nursing program educator for over 15 years. The lobbyist participant, possessing a doctoral degree, has at least five years of experience addressing and examining nursing legislation.
Two major themes were identified. Under the first theme, four subthemes
developed, including (a) Model opposition, (b) APRN apathy or unconcern, (c) deficient Consensus Model understanding, and (d) inadequate relationships with change agents.
Under the second theme, two subthemes emerged, including (a) Model facilitators and (b) preferred strategies.
Theme 1: Roadblocks to Implementation/Consensus
Subtheme 1: Model opposition (Subsystem: Professional associations). In Maryland, certified registered nurse anesthetists (this is all capped here…not consistent) (CRNAs) are required to have a collaborative agreement. Collaboration is defined as “the development and implementation of an agreement between a nurse anesthetist and an anesthesiologist, licensed physician, or dentist concerning the practice of nurse
anesthesia” (Code of Maryland Regulations, 2015b, para. 2). Certified nurse practitioners (CNPs) are required to complete a Maryland Board of Nursing-approved written
for “collaborating and consulting” (Code of Maryland Regulations, 2015c, para. 1). On an as needed basis, the CNP is required to refer to and consult with physician and other healthcare providers. Certified nurse-midwives may independently manage clients
“appropriate to the skill and educational preparation of the certified nurse-midwife and the nurse-midwife’s clinical practice guidelines” (Code of Maryland Regulations, 2015a, para. 2). CNM scope of practice includes consulting or collaborating with a physician or other healthcare provider “as needed” and referring clients “with complications beyond the scope of practice of the certified nurse-midwife to a licensed physician” (Code of Maryland Regulations, 2015a, para. 3). Maryland participants each mentioned physician opposition to removing both collaboration and attestation. One participant stated:
It’s organized medicine that is, they’re protecting turf. They’re afraid. They’re very afraid. And logic and data will never make any difference to them. We’ve got plenty of logic. We’ve got plenty of data. We’ve got years of evidence, you know, if you look at the national practitioner data bank, the number of complaints and actions taken against health care providers…. Many physicians have no idea how we’re educated and, they have no idea what we do too. And so, it’s fear of the unknown, first of all. Second of all, they have invested a lot of time and energy and money in their education and, I think many people have gone into medicine thinking that they’re going to make a lot of money, and many do. But, there are a lot of people in primary care practice, and they’re not making a lot of money. They’re just barely getting by and the world is changing and, I think
they’re concerned for their bottom line, but they’re also concerned for who’s in charge, and they ought to be in charge.
A second participant commented:
It’s like every other turf battle, between different practitioners in Maryland, whether its nurse practitioners and physicians, or CRNAs and
anesthesiologists…they [physicians] want to protect their turf. In a perfect world for most anesthesiologists, I think they’d like to require direct supervision. That’s just not the case. And I don’t think they’re [anesthesiologists] willing to battle us [CRNAs] on that, just like we’re [CRNAs] not willing to battle them
[anesthesiologists].
Subtheme 2: APRN apathy or unconcern (Subsystems: Beliefs and