Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Our guests today are Sarani Hair Kwan, nurse practitioner, and a returning contributor to the show and system director for advanced practice providers at Providence. We also have Cherise Scott, Clinical Nurse Specialist, an associate professor and director for clinical nurse specialist programs at the University of San Diego, and Elizabeth Pelletti, retired certified registered nurse senesthetist, chief nursing executive officer, and vice president of patient care services at Mercy Medical Center, Mount Chasta. Each of our guests is an advanced practice nurse who comes to the topic from a different specialty and perspective. We're having all of them here today to talk about what advanced practice nursing is and how it functions in today's health care and health policy environment. Thank you all so much for being here today. It's so great to have you all on the podcast. And I want to start first with talking about the term advanced practice nurse. And so, Elizabeth, I'm curious if you can help us when we say advanced practice nurse, what does that actually mean and what roles would fall under that umbrella?

Sure, I'd be happy to. Advanced practice nurse is a nurse with an advanced degree, at minimum, a master's degree. Um, many have a doctorate degree. They've been trained to assess, diagnose, and manage patient care in all aspects of healthcare, including geriatric nursing, anesthesia, obstetrics, primary care, behavioral health, and they are an essential piece of all health care.

And I'm curious, turning over to you, Sarani, how does someone become an advanced practice nurse and what do those requirements and pathways look like?

Well, I will say that there's the traditional pathway, which is what I and most of the nurse practitioners I know follow, um, which is, you know, undergrad, then graduate school with a um nurse practitioner degree that is a certification in that program. We are seeing a plethora of programs now. You can be a direct entry program um candidate where you're going in with a bachelor's degree in something completely different and come out with a doctorate and nurse practitioner. It's it's quite remarkable. Uh, things have changed probably more in the last 15 years than I have ever seen in the history of nurse practitioners and um all other uh APRNs. Um but it's it's also true that our other two guests have a um unique entry into their practices, which I think would be great for them to share because we have the traditional college pathway, but I'd love to have Cherie and Elizabeth share how they got into their specialties as well.

Well, I definitely still took the traditional college pathway as well. Um, I was just lucky enough to do that through um my time in the Navy um through what we call duty under instruction. So I was really fortunate. Um the the Navy has a strong clinical nurse specialist um supportive group. So um, but I did still need to take the three Ps, advanced patho, advanced pharmacy, and advanced physical assessment, as all APRNs are required to do. Um at the time, there really wasn't, um, when I graduated, there really wasn't that doctoral pathway. There was really that MSN pathway. Um and then, of course, um, you know, certification um and then licensure as well. I know that Elizabeth, though, had a had a really unique um entry into advanced practice nursing.

Yeah.

So still it was all the college pathway. So just to be clear, I did start out as a BSN with the anesthesia program. There was a requirement for um intensive care experience. So I had um a total of five years of experience as a nurse in the ICU and the ER before. And then I was accepted into a scholarship program with the US Army and went into the U.S. Army's graduate program in anesthesia nursing, proctored through UT Houston, but similar to Cherie, was active duty education. So I was on active duty um learning to be an anesthesia provider or a CRNA.

So we've come a long way from diploma nursing, haven't we? It's quite remarkable.

Yeah.

Yes, absolutely. And I want to share too the listeners on of this podcast also come from many different backgrounds. Um, a lot of them are nursing, some of them might be in general healthcare roles, and they might not be as familiar with the different areas of advanced practice nursing. And so, since each of you represent these different areas of advanced practice, I'm wondering if you can talk a little bit about your specialties and how they differ in scope and responsibilities, because I think that not not everyone might know what's the difference between a CNS and an NP and a CRNA. And so, Cherie, I'm curious if you could start with that and tell us more about the CNS specialty.

Right. So the word specialty or specialist is really at the core of the clinical nurse specialist role. Um, we've our our clinical practice is deeply rooted in specialty, right? And that could be a specialty population or a specialty group, right? So that might be something like you specialize in maybe management of diabetic patients, or maybe you specialize in critical care. Um, but really at the what we all share in common is that we leverage this specialty expertise to improve outcomes. Um, and we do that through direct patient care, um leading evidence-based practice, and certainly optimizing policy and procedure at the organizational and systems level.

That's great. And Elizabeth, I'm curious if you could walk us through your journey as a CRNA and what that entails because I think people are familiar with anesthesiology, you know, and how that looks like for physicians. But uh curious if you could share about the CRNA specialty as well.

Happy to. Nurse andesthetists have a wide range of practice depending on where they're practicing at. In many states, they are practicing as an independent practitioner, uh, LIP, a licensed independent practitioner. They're working on their own. They are not required to have somebody overseeing and signing orders or HPs. They do all of that work themselves. And recently in California, this was actually reinforced with the California AB 876 that CRNAs are qualified and practice independently. In a rural area, it's super essential. It's where I've chosen to do a majority of my practice was in rural anesthesia, and it's 100% independent. We can't find an anesthesiologist to work here. And so we do the same exact scope as an anesthesiologist in a rural area, including pain management, general anesthesia, um, sedation. A lot of times we're helping manage sedations in the intensive care unit on and manage ventilated patients and helping provide uh ER diagnostic lumbar punctures, that sort of thing. So it's the whole scope of practice, but in a metropolitan area, a lot of times the practice is more of a team approach with an anesthesiologist and CNAs working together.

Yeah, thank you for sharing that because there is different levels of independence that you might see with these different specialties depending on the regions at times. So if it's rural, I know that that could be also something we see with nurse practitioner uh scope as well. And and I'm curious, uh Sarani, if you could tell us more about the nurse practitioner role. We've talked about that a little bit in our podcast episodes before, but can you share a little bit more about the nurse practitioner role as well?

Sure. The uh nurse practitioners are found literally everywhere. So the concept for nurse practitioners actually started um in California as a primary care provider, and it just has exploded from there. It was interesting that when you explore the history of nurse practitioners in California, you see nurse practitioners, family medicine nurse practitioners moving into the hospital setting very quickly, almost immediately, and delivering um hospital-based care. They were doing rounding, they were um working in the um hospital settings in multiple specialties. And now when we just got done with our uh annual conference, and uh it was quite remarkable to see the number of nurse practitioners that work in literally every specialty you can possibly imagine. And they do everything. They uh the only thing they do short of surgery is um every line management that you can name, they do uh every tube insertion they can do. Uh, and even some um procedures that used to be considered um uh more complex are now considered uh kind of everyday procedures that you would do even in the ambulatory setting, are being done by nurse practitioners. And so I would say that uh the entry into independent practice started with the bill that we've talked about in the past, Charlene, AB890, and then Senate Bill 1451. And work continues to um uh move forward with that concept because as Elizabeth says, rural health is where you find a lot of nurse practitioners delivering care. They are obviously in big cities working in huge healthcare organizations around the state, but the majority of primary care is really starting to be delivered by nurse practitioners and our PA colleagues out in the rural settings.

And then, Sheree, I have a question too about clinical nurse specialists because it's also fairly specialized expertise in the CNS role. And I see a lot of people confuse a CNS and an NP. And I'm wondering if you can share a little bit of the differences between the two.

Yeah, it's interesting. I think, you know, at the most basic level, when we talk about that question, I I probably used to answer that. Well, nurse practitioners are in primary care and clinical nurse specialists are hospital-based, but I don't think that's really the accurate answer anymore. Um because I think all of both of us can be found in many um ways. I think the difference, um, like the main difference that I see is that um clinical nurse specialists really um focus on system-based evidence-based practice, right? So looking at what does the evidence say, what is the um best standard in care, and then how can we implement that across systems? And that takes many forms, right? We can implement that at the patient um sphere of impact. So at the bedside, providing expert care. You might see a clinical nurse specialist that, you know, uh specializes in cuminin clinics, right? And they're really that's their focus, but it's still a specialty where we also um work in the nurse sphere of impact, right? So we might be using that specialty to train nurses, to make sure nurses are competent to consult um on difficult um um cases. So it really has, I think, um become more blurry than when they the roles first started. Um but there certainly is um many differences, but there's also a lot of similarities. We both are skilled assessors, we're both skilled um treatment uh in treatment and in evidence-based practice and and bringing uh we're both roles, I think, are really focused on patient outcomes.

Yes, and you mentioned the different settings too that you can find a CNS. They might be inpatient, they might be outpatient. And it makes me wonder too about the CRNA practice settings because I think typically people think about nurse anesthetis in an inpatient setting. I'm wondering, Elizabeth, if you can share, are there other settings where we we might also find CRNAs?

Certainly. Most most commonly it is inpatient um operating rooms, but outpatient surgical centers, also pain management centers. There's a lot of CRNAs that were working in pain and pain management clinics that um provide those services and do a great job.

Great. Thank you all so much for sharing the additional information about the various advanced practice roles. And I want to talk more now about the current practice environment for APRNs. And Sarani, I want to talk about specifically the demand for advanced practice nurses because you know there has been so much progression and evolution of advanced practice nursing roles, and of course, the need for them has also changed over time. So, can you share how that demand for APRNs has been changing in California?

Well, we we don't make enough of them in California. That is uh certainly true. And um, and I I can attest that even in the last 20 years, to Cherie's point, the growth of programs in California has been uh through the roof. So you have seen traditional family medicine programs start to expand and include uh adolgero. They add psych mental health NP options. Uh, you can do a post-master's certificate, a one-year certificate. If you're already a nurse practitioner in a specialty, you could do that and become a psych mental health NP as well. And um, and then all of the other specialties that are um the APRs that are starting to emerge, we don't have, I think, we don't have enough CNF schools in California, and uh we don't have enough CRNA programs in California or midwife programs, all like all of them. So I think that um that the number of uh people that we need in the state to take care of the population uh in the next 10, 20, 30 years is gonna have to grow. And certainly we have um people being trained from other places in the United States and coming into California to work. Um, that transition can be a little rocky for our out-of-state um um colleagues that are coming in to practice, say, as a CRNA, a CNS, or an NP or a midwife. Um, but it is um also uh difficult in any practice environment because we are continuing to face barriers in um uh advancing into uh areas to deliver care. So while we have traditional spots where we are found uh all APRNs, um I, for instance, would love CNSs in the ambulatory setting because they are really the experts in driving evidence-based practice. And um it is almost impossible to find a C a CNS uh able to work in the ambulatory setting, but certainly um convincing your organizations that it's uh the right thing to do is one of, I think, the hardest first steps. So it's not just it's not just that we're gonna struggle with the a number of people that we have in the state, but it's also that healthcare organizations have got to start thinking um into the future about what does patient care look like and what would benefit the delivery of patient care in every setting that we have moving forward. So I think that for me is really about taking down the barriers that have prevented APRNs from moving forward in practice. And I'm not talking about changing what we do, I'm just talking about changing where we're found and uh and the recognition of the work that we do.

Right. And it sounds like the demand for APRNs can really be seen in the need for increased numbers of APRNs and then also increased need for different settings, you know, different um placements for them because there's just so much possibilities of the of the services that they can provide. And it makes me wonder about other existing challenges that we might see that APRNs are facing. And Cherie, I'm curious if there's any additional challenges you might see, you know, whether it's from a CNS perspective or other APRNs, but what else um are they seeing in today's environments that might really be impacting their practice?

Well, I would be remiss in this opportunity to, I have two points, but the first one is probably more specific to the clinical nurse specialist role than all the APRN roles, but I do one of the biggest barriers I am seeing is role clarity. Um, I am seeing um roles that are advertised for the advanced nurse clinician or the nurse specialist, right? Where we can take somebody with a master's degree and say, we don't want to pay for a CNS, so instead we're gonna have this other um nebulous term that we're gonna use and maybe pay them less and hope that we get the same outcomes. So I think role clarity is absolutely important across all of our roles, but I think right now the clinical nurse specialist is facing it head on. But I would say a larger, if we're talking at APRNs, um, one of the larger challenges facing us right now is this tension about who controls delivery of healthcare, who controls reimbursement, what are the professional boundaries, right? I think um in Sarani and I's previous conversation, she used this great word resistance. And I was I was like, wow, that's it. That's the word, right? Primary care is really, I think, where this is most visible. Um, you know, uh this is there's uh it's high demand, it's revenue generating, and it's experiencing shortages. And so I think um we might be especially in the MP role. Um, you know, we're we are positioned as APRNs to solve this gap, right? But at the same time, um if if there's this back and forth pool that we're somehow taking the jobs or taking the reimbursement or taking the work um resistance to our scope, then we're not gonna be able to be that solution to those gaps, particularly as we've mentioned in those rural and underserved areas.

Right. And it sounds like when it comes to APR in practice, there's really this coupled um challenge that we see. And from the from the team role um perspective, there is this challenge of role clarity. So as all these different roles evolve and as more complexities are occurring in the different care settings, there is more blurred lines in terms of who does what. And that can especially be seen in nursing roles and advanced practic uh advanced practice nursing roles. And so the question of who does what becomes a really big one. And then also scope creep is a little bit of that part of that as well. So Absolutely. And I'm curious too, Elizabeth, from your perspective from leadership, because from the perspective of a chief nursing officer or other nurse leaders who might be working with APRNs as part of a larger system or larger team, what would you say are best practices for effectively integrating APRNs?

Um I think it's absolutely essential that CNOs meet with their APRN groups and really understand their scope of practice, really advocate for a practice at the highest level of their license. It facilitates care at that organization, ensures patients are getting the care they need. And it really promotes a safe collaborative environment across the board with all of the specialties. Um, I know one of the first times I reported up to a CNO and she and I chatted and she told me she had no idea what I did, what my role was. And I think that's quite common across the board is that many CNOs don't understand the role. I think that's slowly changing. I know in my organization, um our APRN leadership is invited to all of our CNO leadership meetings as well, and they um provide updates and work with scope of practice and onboarding orientation, making sure we're doing the best we can to provide that advanced practice role.

Right. There can be challenges when you think of the perspective of a CNO if they don't have the background or the clinical background as an advanced practice registered nurse. And given that there's so many different types of APRN roles, it could be really easy to have a CNO who might not understand all of those details and nuances when it comes to you know these four different APRN roles. So that is a lot of information and that is a big gap potentially. So what you're saying, you know, in terms of that visibility from the CNO and having that collaboration, so there could be more thoughtful ways to integrate APRNs could be a best practice and um really having more of that dialogue, I would say. Definitely. And there's also many challenges when we zoom out more and think about policy, right, from a statewide perspective. And Sarani, you are currently our co chair for our ACNL Health Policy Committee and of course our favorite person to talk to when it comes to. Recent and upcoming legislation. And when we zoom out and when we think about legislation right now and what's in the pipeline, could you walk us through what is in the pipeline right now for advanced practice nurses?

Well, I would say that every year we are seeing legislation that is seeking to uh kind of unveil the availability of APRNs in the workforce everywhere, in every setting. And uh certainly true with the ACNL Health Policy Committee too, the the importance of supporting all of our colleagues, not just APRNs, but also nursing legislation, in uh recognizing the value of nurses in every setting and certainly APRNs and delivery of care. So I think what the future is holding, uh we had uh a bunch of CRNA bills in the last two years. And we have um the nurse midwives have a couple of bills that are going to be active this year. The nurse practitioners haven't yet released anything, but we certainly are uh working on um addressing the issues that are um being generated by us stepping into uh more independent role. And certainly the CRNAs addressed that in the legislation just recently because the um way CRNAs got independence was um an interesting route. And so uh codifying it into law was the most important thing to do, which is um why that legislation was put forward for CRNAs. And um, and so the same is true with the CNMs. Uh the midwives also have independence in certain settings. So there is a continual um cleanup, I should say, a legislative cleanup of the language, because uh things get misinterpreted or put into um practice that are not following the law. And so going in to clean that up and make the law more crystal clear is important. So our APR and colleagues can continue to deliver the care that our patients in the state of California so much deserve. So I think that's more of what's coming down the pipeline than anything. It's just constantly cleaning up and looking at where our barriers are. We've got um a lot of barriers around um practice management and ownership that need to be addressed. So at this point, um, all of us could um own a nursing corporation, but we don't actually have the legal authority to have patients. You need a medical corporation for that. So I think that is the next big topic that will be on everyone's minds in the coming couple of years.

Right. And it's almost as though with all of the advancements we've made in nursing, it's almost as though legislation is constantly trying to keep up with all the changes and all the meeting needs, right?

Yes, absolutely.

And I wanted to ask too, how can people find information about this pipeline? What would you suggest if they are wanting to stay up to date?

Oh, well, ACNL, we have great information. I would encourage you to join committees. Uh, we have very active committees on ACNL, and certainly the health policy committee is a very active one. But I want to also encourage all the listeners that if they are an APRN of a different um stripe, that you get involved with your professional associations because membership is really the most important way to stay abreast of what's going on in your um your role. And I think the questions that Cherie brought up about role clarity are spot on. And uh we certainly, the nurse practitioners have certainly spent a number of uh years supporting our CNS colleagues. Um, I may be in Sacramento talking about an NP bill, uh, but if there is a CNS bill that is adjacent, I'm gonna talk about that as well. Because I work with CNSs and I know the value that they bring to the organization. And certainly CRNAs, um, to Elizabeth's point, um, recognizing the value of CRNAs in every setting, uh, they there has been for so many years this concept that they're just hospital-based because they can be, you know, uh supervised by anesthesiology is, you know, a very outdated idea. And so I would argue that the CRNAs in the state of California are actually one of the more active professional groups because almost 100% of graduates coming out of CRNA school belong to their state association. So ACNL is one of those um really wonderful uh groups that kind of crosses all specialties and um and really gets nurse leaders uh to um become more aware of all of the things that are happening in the state and uh both at on the ambulatory side and the acute side. So I say get involved and uh and read what we have to say. We have a great newsletter that the um health policy team puts out. But every professional association, for all of the roles that we've talked about today, including the nurse midwives, they have uh wonderful updates on their websites that uh you can easily find and uh research and certainly reach out to them if you need more information about a particular topic as it relates to your healthcare organization.

Yes, there's a lot of resources we could find within ACNL, within different professional nursing organizations. And that makes me wonder too about nurse leaders within different healthcare systems. And Elizabeth, just wanted to hear from you in terms of nursing leadership supporting APRNs, how would you say they can do so both operationally and through advocacy, you know, when we consider the different challenges that we discussed today?

So a lot of that is really encouraging the APRNs to get involved, to join their associations. And the nice thing about anesthesia, I don't know, when I was in school, it was mandatory that we signed up for A. And so we were all mandatory members of students and just kept that through the years. And then, you know, California Association of Nurse and Esthetis is a great organization branch off of that national organization. I think nurse leaders have to support that involvement, really encourage their APRNs to get involved in the committees, but also to come to the local hospital meetings, to come to the med staff meetings, even if you're not a voting member, having your voice heard is absolutely essential. If your voice is never heard because you don't come and you don't speak up, you'll never affect change. And the only way to do that is to be involved.

Totally agree with Sarani. And that's a great point that you mentioned too about membership, because the reason why I joined ACNL in my nursing career is because my chief nursing officer at the time um, you know, and uh really encouraged the membership. And she paid for my membership and my, you know, my registration for my first ACNL conference, and I never left after that. So it really makes a huge impact when there's that encouragement and role modeling for organizations and for involvement. So so that's a really great point to think about. And when we think about the future too, you know, looking ahead five years, Sheree, I'm curious if you can share how do you see all advanced practice nursing evolving in California and nationally?

So I would I would again say twofold. Um the first is specialty care gaps. We have these specialty care gaps that APRNs are so ready to fill. And the ones that come to mind um first for me are the shortage of ECMO profusionists, right? And so we're seeing um an increase in ECMO nurse specialists. Um I know many CNSs now that that is their specialty of practice. Um but that's just one example of how we can fill these gaps. Um certainly in the post-acute world, you know, our healthcare system is continuing to move to a post-acute um care environment, right? Not just that acute care hospital. And APRNs are well positioned to fill those specialty gaps as well. We have a CNS umorena who, you know, she oversees uh post-care facilities up and down the state of California. It's just amazing. That is her area of specialty. And then of course, I would be remiss not to bring it back to my earlier topic, which is you know, that um really understanding that uh primary care need. Um so the specialty care need, but then on the opposite side of the spectrum, we really need to address that primary care need. And I think through advocacy, through policy, you know, as a clinical nurse specialist, we are pursuing full practice authority in the state of California. We we have to support the nurse practitioners, we have to support all those APR enrolls if we're going to meet these gaps in care in both the primary care setting and those specialty care areas.

Yeah, so really thinking about advanced practice nursing in the future is really thinking about advancing this practice for us, right? So that's whether that's whether that's more specialty care or more focus on primary care as well and more um integration in that. Uh, these are all really key ideas to keep in mind for the future and and talk about now so we could prepare um for that advancement. And as we wrap up today, if there's any final words that you'd like to share with our listeners, I'd invite you all to share.

Well, I'm just gonna say uh get involved. So you don't have to become an advanced practice nurse. Uh you can be a nurse leader. Um, but but staying involved with your uh APRNs, I think is a key way to be successful in your organization.

You absolutely were reading my mind. Getting involved was exactly the word. It makes such a difference when we have voices from up and down the state in our organizations. It increases the support, and this is how we will move these initiatives forward. If we want to progress over five years, it can't be just a few voices, it's got to be all of our voices together. Absolutely.

And if you're a nursing leader, know your APRNs, what their scope of practice is, and promote them. They're going to be providing the care to all of us as we need it. Right.

And thank you all so much. That was so much wisdom that you shared with us today. And really appreciate you all for being here and for representing Advanced Practice Nursing.

Thank you. Thank you so much for having me.

Our guests today were Sarani Harakwan, System Director for Advanced Practice Providers at Providence, Sheree Scott, Associate Professor and Director for Clinical Nurse Specialist Programs at University of San Diego, and Elizabeth Pelletti, Chief Nursing Executive Officer and Vice President of Patient Care Services at Mercy Medical Center Mountchasta. We'd love to hear your feedback. Email us at social media at acnl.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is brought to you by the Association of California Nurse Leaders with new episodes on the first Friday of every month. To learn more about the show or ACNL in general, visit us at acnl.org. Thank you for listening.