Advanced Emergency Nursing Journal
Vol. 40, No. 2, pp. 73–77
F R O M T H E
Editor
K. Sue Hoyt
Emergency Nurse Practitioners State
Downloaded from https://journals.lww.com/aenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD38k+bDukTnmYBRphaf6yoiyNY068aJMc97SyFKWqve7/fjBekaEFpsQ== on 06/02/2018
by State
A Call to Action
Today’s emergency nurse practitioners
(ENPs) bring several competencies to the
table—those of knowledge through formal
and ongoing education and skills through
procedural training, in addition to a wealth of
clinical experience. Emergency nurse prac-
titioners across the country, however, have
been dealing with practice issues, specifically
about state law and regulations. Some ENPs
have been informed by their respective
hospitals employers or the physician groups
that they have contracted with, that they
are unable to practice in various emergency
care settings (i.e., emergency departments
[EDs]). This is, at times, based solely on
the misinterpretation of ENPs’ educational
background and the core population they
serve (e.g., family, acute care).
In the From the Editors column, the au-
thors hope to clarify the Consensus Model for
Advanced Practice Registered Nurse (APRN)
Regulation: Licensure, Accreditation, Certifi-
cation and Education (American Nurses Cre-
dentialing Center [ANCC], 2008) statements
about specialty practice. It is also our in-
tent to utilize the framework of the Amer-
ican Nurses Association (ANA), Determin-
ing Scope of Practice for Advanced Practice
Registered Nurses (APRNs), which delineates
Disclosure: The authors report no conflict of interest.
DOI: 10.1097/TME.0000000000000192
73
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Copyright 
C 2018 Wolters Kluwer Health,
Inc. All rights reserved.
scope for APRNs, including ENPs. Finally, we
conclude with a “call to action.”
CONSENSUS MODEL AND SPECIALTY
PRACTICE
In 2008, the Consensus Model became the
framework for nurse practitioner (NP) licen-
sure, accreditation, certification, and educa-
tion (ANCC, 2008). This model delineated the
advanced practice nursing based on role (e.g.,
NP) and population-focused competencies
(e.g., family/individual across the life span;
ANCC, 2008). Specialty practice encompasses
additional competencies that build upon areas
of role and population. It is at the specialty
level within the Consensus Model that con-
cerns about scope of practice have surfaced
(Hoyt & Proehl, 2015).
To date, the authors of the Consensus
Model document, the ANA, the National
Council of State Boards of Nursing (NCSBN),
and the National Organization of Nurse Practi-
tioner Faculties (NONPF), have offered much
discussion about the role and scope of ENPs
working in the specialty of emergency care.
And, the American Academy of Emergency
Nurse Practitioners (AAENP) has and will con-
tinue to adhere to the tenets set forth in the
Consensus Model. Unfortunately, there are
still several discussion items surrounding ENP
specialty practice.
 74
DETERMINING SCOPE OF PRACTICE
According to the ANA, the Determining
Scope of Practice for Advanced Practice Reg-
istered Nurses (APRNs) was written to delin-
eate scope for APRNs, which include ENPs.
The following areas must be considered when
determining practice: (1) scope and standards
of practice, ethics, and certification; (2) state
law and regulations; (3) institutional policies
and procedures; and (4) self-determination,
and professional liability and risk manage-
ment concerns (ANA, 2018) (see Figure 1).
Scope and Standards of Practice, Ethics,
and Certification
ANA states the scope and standards of
practice are “the “who,” “what,” “where,”
“when,” “why,” and “how” of nursing” for
all nursing, including advanced practice nurs-
ing. The ANA also recognized specialty doc-
uments specific to practice based upon the
organization established to develop those
statements (scope and standards). The ANA
has recognized emergency nursing (RNs and
APRNs) as a specialty practice since 2011
(Emergency Nurses Association [ENA], 2011).
The scope and standards for ENPs were es-
tablished in 2016 by both the ENA and the
AAENP. Competencies for NPs in the ED had
been established since 2008 and endorsed by
the NONPF and other stakeholders. As per the
ANA and the Consensus Model, these doc-
uments support the scope and standards of
practice for the NP in the ED.
State Law and Regulations
The ANA has determined that the practice of
the APRN is explained by each state’s nurse
practice act and governed by the specific state
boards of nursing (ANA, 2018). Each state may
have its own additional documents or provi-
sions. Specific acts in a state by APRNs may be
provided in the form of opinion by the state
board of nursing. This is where the area of
practice becomes blurred. For example, many
states are responding to the individual ENP,
hospital system, or physician group and even
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Advanced Emergency Nursing Journal
Figure 1. A model for defining practice and
acceptable competence. Considerations 1-4
are depicted graphically. The American Nurses
Association (ANA) Committee on Nursing Practice
Standards and Guidelines has formulated a model
to clarify the roles and relationships associated
with regulation of all nursing practice. The model
recognizes the contributions of professional
and specialty nursing organizations, educational
institutions, credentialing and accrediting or-
ganizations, and regulatory agencies; clarifies
the role of workplace policies and procedures;
and confirms the individual nurse’s ultimate
responsibility and accountability for defining
nursing practice. The ANA Committee on Nursing
Practice Standards and Guidelines has formulated
a model to clarify the roles and relationships
associated with regulation of all nursing practices.
The model recognizes the contributions of
professional and specialty nursing organizations,
educational institutions, credentialing and ac-
crediting organizations, and regulatory agencies;
clarifies the role of workplace policies and
procedures; and confirms the individual nurse’s
ultimate responsibility and accountability for
defining nursing practice. This model is relevant
regardless of the degree or level of nursing being
practiced. Adapted from the Model of Profes-
sional Nursing Practice Regulation, by American
Nurses Association, 2018. Retrieved from
http://www.nursingworld.org/EspeciallyForYou/
AdvancedPracticeNurses/Scope-of-Practice-2/
Scope-of-Practice. Copyright 2018 by the
American Nurses Association. Adapted with
permission.
 April–June 2018 r Vol. 40, No. 2
developing position papers without acknowl-
edging the work of the specialty organizations
as prescribed by the Consensus Model and the
ANA. Even states that don’t adhere to the Con-
sensus Model still have direct responsibility
to acknowledge the specialty organizations’
science behind their practice. The ENA and
the AAENP (specialty organizations responsi-
ble for the specialty practice) have valid and
reliable scientific evidence of scope and stan-
dards of practice, competencies, guidelines
for academic and fellowship programs, and
certification examinations. Thus, some state
boards have offered varying statements that
have not recognized the extensive work of the
specialty professional organizations of emer-
gency care and are not consistent with the
Consensus Model. Opinion or position state-
ments may have little authority but yield great
influence on hospital institutions and physi-
cian groups when attempting to hire–fire and
credential ENPs. The institutional policy and
procedure then become tainted.
Institutional Policies and Procedures
Here are a few examples of written statements
by state boards of nursing that leave ENP ex-
perts perplexed:
Nurse practitioners in the ED must be cer-
tified in the population of acute care. How-
ever, the Centers for Disease and Control and
Prevention (CDC) clearly state than more than
40% of the more than 141 million patients
seen in the ED are women and children and
only 3%–5% are critical care patients. There-
fore, an acute care nurse practitioner by edu-
cation and certification does not possess the
scope of practice to see the bulk of this pop-
ulation (CDC, 2014).
Family nurse practitioners (FNPs) cannot
work in the ED because they have no acute
care training. Although not trained in acute
care, the FNP is trained to provide resuscita-
tive care and primary care in the ED. Family
nurse practitioners are certified to see pa-
tients across the life span according to the
Consensus Model (ANCC, 2008 ). This knowl-
edge, these skills, and many abilities were
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Emergency Nurse Practitioners State by State 75
identified over a decade ago in the Competen-
cies for NPs in Emergency Care (ENA, 2008).
They have also been documented in the aca-
demic curricula of ENP programs for several
decades and most recently were revalidated
in the ENP practice analysis, which was the
basis for ENP certification examination (ENP-
C).
The specialty educated and certified ENP
cannot work in the ED because this indi-
vidual does not have acute care training.
In a comparison of the acute care competen-
cies (NONPF, 2004) with the competencies
for NPs in emergency care (ENA, 2008), the
evidence is beyond refute.
The ENA and the AAENP concur that
providers in the ED be educated in the
specialty of emergency care. That is the
recommendation of the both specialty
groups—and these groups are the experts.
The need for emergency care, established
practice, formal and informal education, pro-
fessional organizations, scope and standards,
competencies and now the ENP certification
are now the foundation for the ENP specialty.
These cornerstones have been established to
ensure that ENPs will provide high-quality,
safe care for patients seen in all areas of
emergency care.
Self-Determination
Self-determination is another component of
the ANA model that support the practice of an
APRN in a specialty. Emergency nurse practi-
tioners in the ED should be aware of their state
nurse practice, as well as ENA and AAENP po-
sition statements. ENPs should also be pre-
pared to articulate their scope of practice
when working in the ED by disclosing educa-
tion, both formal and continuing education,
in the specialty practice based on the compe-
tencies for NPs in the ED.
Professional Liability and Risk Management
Concerns
The final component to consider in context
to APRN regulation is professional liability
and risk management. Professional liability is
 76
the state of an ENP being legally responsible,
accountable, and answerable for actions un-
dertaken; risk management is the forecasting
and evaluation of risks together with the iden-
tification of procedures to avoid or minimize
the impact of liability. These issues become an
even greater concern for ENP employers who
read statements from state boards of nursing
and are then wary about employing ENPs.
A CALL TO ACTION!
The issue regarding scope of practice is due
in part to state boards of nursing compos-
ing these opinion statements to further clarify
ENP scope of practice without the acknowl-
edgement of the ANA document (ANA, 2018)
or the adherence to the specialty component
as outlined in the original Consensus Model
document (ANCC, 2008). Furthermore, spe-
cialty organizations such as ENA and AAENP
are not routinely queried by ENP employers
with regard to their scopes, standards, certi-
fication, and competency information, which
would help clarify this ongoing issue. As hos-
pital credentialing committees and/or group
practices review each state’s opinion state-
ments, in light of rendering a decision about
the hiring of an ENP, time and time again,
it has been noted by ENP experts that these
groups were misinformed. Furthermore, insti-
tutions and group practices may have quality
improvement and risk management concerns.
For example, if the parties providing the infor-
mation are not equipped to fully answer the
queries, these groups will ultimately “err on
the side of safety.” In other words, the ENP
is not hired for the position. The issue ap-
pears to reside with state boards of nursing,
which are remiss in acknowledging the ENP’s
specialty and body of science, which would
have provided clear evidence of that ENP’s
qualifications. That evidence includes the dis-
tinctive knowledge, skills, and abilities of the
ENP educated as an FNP with an emergency
care specialty.
AAENP is working diligently with the
NCSBN, the NONPF, the American Associa-
tion of Colleges of Nursing, and most specif-
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Advanced Emergency Nursing Journal
ically the state boards of nursing to educate
these nursing organizations. The AAENP con-
tinues to articulate our ENP competencies
so as to clarify our position. The Consensus
Model was not created to assist ENPs in losing
their current positions of employment. The
model was meant to support, promote, and
provide clarification for ENPs.
Emergency care is a unique specialty. Emer-
gency nurse practitioner have complied with
the Consensus Model. It is incumbent upon
us to continue to inform the various state
boards of nursing about our ENP scope and
standards, ENP competencies, and ENP certi-
fication. It is also imperative to protect and
defend all ENPs who have and continue to
work in emergency care. We must safeguard
our disenfranchisement by those who are un-
informed and/or those who have misinter-
preted our scope of practice.
Please contact your AAENP regional or state
representative for additional information. If
you have a story to share, we’d love to hear
from you. We will continue to be a united
voice!
—K. Sue Hoyt, PhD, RN, FNP-BC, ENP-C,
CEN, FAEN, FAANP, FAAN
Editor
Advanced Emergency Nursing Journal
—Elda G. Ramirez, PhD, RN, FNP-BC,
ENP-C, FAEN, FAANP, FAAN
Founder
American Academy of Emergency Nurse
Practitioners
Professor of Clinical Nursing & Director of
Emergency/Trauma Nurse Practitioner
Concentration
University of Texas Health Science Center
Houston
Houston, TX
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