The Nurse Midwife delivers essential maternity care especially in rural areas. A barrier to
practice for the Nurse Midwife is clarification of scope of practice and clarification of
midwifery roles, according to the World Health Organization (WHO) (2018). Hastings-
Tolsma et al., (2018) found that there is a “lack of differentiation from nursing and
midwifery” which has created a lack of differentiating the care the midwife provides
from that of the nurse. This makes it difficult on both state and national levels to push for
legislation due to lack of workforce studies regarding retention of midwives and
improvement of quality care.
The Certified Registered Nurse Anesthetist face practice barriers related to being able to
perform their duties with or without a supervising Anesthesiologist. Currently, Virginia
does not require the CRNA to be supervised by the Anesthesiologist. There are 27 states
in which the CRNA can practice autonomously without a collaborative agreement or a
supervising Anesthesiologist. The other remaining states require the CRNA to be
supervised. This places limitations on the CRNA to perform their duties as they wait for
an available Anesthesiologist for supervision. This creates difficulties in rural areas
where smaller hospitals rely on the CRNA for procedures.
The Clinical Nurse Specialist faces prescriptive barriers on the state and national level.
According to Mayo, et al., (2017) there has been a push for nurses to practice to the
fullest extent of their licensure, however, the CNS faces prescriptive barriers and unable
to fully practice. According to NACNS, the CNS has varying levels of prescriptive
privilege in 35 states and is currently dependent on a physician agreement before they can
prescribe in Virginia. Therefore, the CNS has limited prescriptive authority and is unable
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