NR 510 Week 1: Introduction and NP Practice
DeNisco, S.M., & Barker, A. M. (2015). Advanced practice nursing: Essential knowledge for the profession (3rd
... [Show More] ed.). Retrieved from https://bookshelf.vitalsource.com
• Part I—Professional Roles for the Advanced Practice Nurse
• Part IV—Theoretical Foundations, Research, and Evidence-Based Practice
Buppert, C. (2015). Nurse practitioner’s business practice & legal guide (5th ed.). Retrieved from https://bookshelf.vitalsource.com
• Chapter 1—What is a Nurse Practitioner?
Journal Readings
American Association of Colleges of Nursing. (2011). The Essentials of Master's Education in Nursing.
The Consensus Model on APRN Regulation (Links to an external site.)
NONPF Competencies
Introduction and NP Practice
Historical Development of Advanced Practice Nursing
The road to advanced practice for nurses in the United States has required patience, dedication, and advocacy (Barker, 2009). The historical development of the role dates back to 1965 when nurse Loretta Ford and physician Henry Silver, from the University of Colorado, suggested that a nurse practitioner (NP) could best alleviate the primary care shortage (especially in the area of pediatrics) and developed a pediatric nurse practitioner plan of study. Their efforts were met with much resistance from both the nursing and medical communities (Hain & Fleck, 2014). Nurses thought such a role was "playing doctor," whereas physicians thought such a role was "practicing medicine without a license." However, the early work by Ford and Silva paved the way for advanced practice nursing (Buppert, 2011). Eventually four advanced practice nursing (APN) roles emerged, that of the Certified Nurse Midwife/CNM (Avery, Germano, & Camune, 2010; Kelley, & Klopf, 2008), Certified Nurse Practitioner/CNP (Baker, 2010; Dierick-van Daele et al., 2010; Frisch et al., 2010; Goroll, & Mulley, 2009; O'Neill, Moore, & Ryan, 2008), Clinical Nurse Specialist/CNS (LaSala, Connors, Pedro, & Phipps, 2007), and Certified Nurse Anesthetist/CRNA (Galvin, Dewan, & Rockoff, 2009). In 2017, APNs can further specialize within these roles to include expertise in Mental Health, Geriatrics, Acute Care, and Palliative Care (Hain & Fleck, 2014).
Some important professional organizations that contributed to early role development include the American Association of Nurse Anesthetists (AANA) and the American Association of Nurse Practitioners (AANP), both with a largely clinical focus; the American College of Nurse Practitioners (ACNP), with a largely legislative focus; and the National Organization of Nurse Practitioner Faculty (NONPF), with a largely educative focus. Initially, many nurse practitioners were actually prepared through certificate programs, much like the nurse anesthetist of that day. Historically, nurses would complete intensive diploma nursing programs at a given hospital and then move on to complete hospital-based certificate programs as a nurse clinician or nurse anesthetist. As nurse clinician programs grew in popularity, and as the minimum level of entry began to move to university-based education, the hospital certificate programs moved as well, leading to specialty education at the graduate level in order to obtain advanced practice credentials. Despite the movement from generalist to specialist education, the commitment remains first to nursing, then to specialization such as the advanced practice role, and then to sub-specialty role development such as the role of the nurse practitioner (Kass-Wolff & Lowe, 2009). In addition, a wide and differing variety of professional preparation requirements, continuing education mandates, and/or standards of practice exist that are unique to each state (Yoder-Wise, 2012). Credentialing remains a confusing discussion among APNs and even more confusing to laypersons, other healthcare professionals, legislators, and payers (Bishop, 2014).
With the emergence of these APN roles, delivery of healthcare in the year 2017 has progressed past augmenting care in traditional MD/DO practices. APNs are now practicing in such diverse settings from the operating room to owning their own practices where the delivery of care is independent of physician oversight. Even with the diversity of care delivery models, state governance of APN practice continues to differ widely with regard to scope of practice, level of autonomy and individual certification requirements (IOM, 2011).
Credentialing
The APN and public alike continue to suffer from role confusion, partly due to the unstandardized format for credentials that vary based on type of APN and certification body. Eunice Cole, past president of the American Nurses Association, once clarified the issue in writing, recommending that one only list the highest earned degree in a given discipline, followed by licensure, state designations, national board certifications, and concluding with honorary awards (Smolenski, 2009). To summarize, the degrees earned appear first (these are credentials such as MSN or PhD that can never be taken away). Next, licensure information appears (these are credentials such as RN or ARNP that is regulated by the state). Certification credentials then follow (these are credentials that aren't necessarily regulated, like APRN, BC from the American Nurses' Credentialing Center [ANCC], which is earned through testing and renewal, or NP-C from the American Academy of Nurse Practitioners [AANP], which is likewise earned through testing and renewal). Finally, honorary credentials would follow, such as FAANP.
Specialization
Initially, the role of the NP was limited to primary care (Goroll & Mulley, 2009). The role of the APN now manifests at graduate-level entry, the objective of which is to blend preparation regarding primary care, education, administration, informatics, case management, and/or role specialization. The notion of role specialization encompasses a concentration within a selected field regarding a given aspect of nursing, whereas an expanded role includes the notion of acquiring new practice knowledge and skills. Role specialization can include a focus in geriatric care, palliative care and mental health.
Advanced practice nursing provides the nurse with the opportunity to make a larger contribution to person, environment, health, and nursing. Advanced practice nursing offers a graduate foundation that utilizes advanced skills, knowledge, and integrative abilities in assessment, planning, diagnosis, implementation, and evaluation of healthcare. A sophisticated level of skills, knowledge, and integrative abilities offered at the point of care contributes to improved health outcomes. The advanced practice nurse builds on advanced pathophysiology, pharmacology, and health assessment skills, knowledge, and integrative abilities to intervene on behalf of the person to restore, maintain, and/or promote health at a higher level than the generalist nurse. The advanced practice nurse is a specialist in healthcare delivery.
Unfortunately, clear definitions for the various roles of CNM, CNP, CNS, and CRNA have been blurred by various state definitions that confuse the roles and often obfuscate their intended meaning. For example, in some states the definition of Certified Registered Nurse Practitioner (CRNP) has been specifically used to refer to all four advanced practice roles of CNM, CNP, CNS, and CRNA (Lowe, 2010). Such state definitions reveal further confusion with regard to role separation, competency, emphasis, approach, and variation. This confusion extends to nurse educators, providers, reimbursement, and even the public. In addition, a lack of clarity regarding initial role preparation versus current certification serves to further frustrate accreditors, consumers, and employers alike. More recent attempts to designate direct care versus indirect care roles have only heightened this frustration.
Philosophical and Theoretical Perspectives
According to Cody (2011), "philosophical and theoretical perspectives" for advanced practice nursing require an additional perspective that suggests it is insufficient to expect that advanced practice competencies are limited to advanced skills, knowledge, and integrative abilities. The need for statistical skills in order to evaluate the level and quality of evidence is foundational for application of evidence to the point of care (Straus, Glasziou, Richardson, & Haynes, 2011). The need for a strong philosophical and theoretical foundation for evidence-based practice cannot be understated, which we will learn as we progress through this course
Systematic Inquiry and Evidence-Based Practice
Would it shock you to learn that "there is increasing concern that most current published research findings are false" (Ioannidis, 2007, p. 124)? Evidence-based practice (EBP) is a concept that is often found in the literature but is frequently misunderstood. For example, at the minimum, EBP requires systematic inquiry (as opposed to integrative review of literature) and both leveling and grading of the quality of evidence (AGREE, 2001; GRADE, 2000). Moreover, EBP is a process that fosters adoption of the most effective patient care innovations and discarding of the ineffective ones so that clinical decisions are made on the best evidence related to patient outcomes. The Magnet Recognition Program of the American Nurses Association Credentialing Center mandates a systematic inclusion of evidence-based practice as the basis for clinical decision-making. You will strengthen your skills in the evidence-based practice by employing a disciplined approach.
EBP includes the following steps.
1. Asking clinical questions
2. Searching the literature on a topic of concern
3. Reading best evidence and critiquing research literature
4. Implementing best evidence in educational and healthcare practices
As a nurse leader, you must be aware of possible barriers to adoption of EBP innovations. You will need to implement EBP strategies to facilitate practice change in the advanced practice setting (Straus, Glasziou, Richardson, & Haynes, 2011).
Organizational Barriers to EBP
Who are the decision makers?
In some organizations, nurses do not sit on the committees or belong to the groups that have formal decision-making power. If this is a characteristic of the organization, the nurse leader should ensure that nurses are represented in all major decision-making bodies. One strategy that can be successful is for the nurse leader to participate in revisions of the mission statement of the organization to ensure inclusion of values important to nurses and quality patient care.
Does the structure support EBP?
The nurse leader can create structures focusing on efficient internal communication in the organization. In general, a decentralized administrative structure and shared governance, including unit-level committees that share responsibility for research, create better opportunities within the organization for support of EBP. A basic need related to structure within the organization is provision of adequate resources and personnel so that nurses can participate. EBP can be very time-consuming. The nurse leader sets the agenda and priorities for the department of nursing and can influence these for the entire organization
Is EBP a performance expectation?
Participation in EBP activities can be included in responsibilities of nursing staff, in annual performance appraisals, and as criteria for raises. Another motivator that can be implemented at the organizational and department level is that participation in EBP activities becomes a method for advancing on a career ladder. Nurse leaders can also develop a budget line that includes monetary grants for EBP projects and for pilot studies, research studies, and development of setting-specific protocols.
Is there resistance to change?
In addition to this human tendency, some nurses do not have the skills to implement evidence-based practice, especially in reading, understanding, and critiquing research evidence. Another issue is that nurses who want to adopt innovations may feel isolated and may not know how to implement change in their settings. These issues should suggest to the nurse leader that methods to support and educate nurses in all aspects of evidence-based practice are important. Strategies include starting journal clubs and research committees that are multi-disciplinary in membership to develop skills in reading research and implementing evidence-based practice innovations. Nurses can be sent to research or other relevant conferences, and experts can be brought into the organizations for consultation. These last two strategies improve the external communication of the organization. The nurse leader can support individual nurses and groups of nurses as adopters of EBP by creating a climate that supports EBP by giving permission to ask clinical questions.
What is the organizational culture?
Some barriers related to the innovation parallel the characteristics identified by Rogers in her diffusion of innovation theory (as cited in Alligood, & Tomey, 2010; Crow, 2006; Rogers, 2003). The nurse leader should ensure that potential innovations are high on the organizational culture, as found in the characteristics suggested by Rogers above. An additional barrier, related to research evidence, is that there may not be credible research with consistent findings available to support the development and adoption of an innovation. The nurse leader can support EBP by ensuring that the strongest available evidence is used as the basis for all policies and procedures used in the care of patients. This will demonstrate the value placed on EBP and will demonstrate the relevance of evidence in day-to-day practice, assisting in cultural adaptation.
Is the staff research savvy?
Communication barriers include the difficulty in reading research evidence, especially quantitative analyses. The leader will need to identify a group of nurses who can understand and interpret research findings to all of the staff to ensure that EBP is fostered.
Outcomes
1
Analyze the development of advanced practice nursing roles from a historical perspective including the impact of advanced practice nursing on the healthcare delivery system from the perspective of selected current reports (i.e., LACE, IOM, etc.)(PO 3)
Weekly Objectives
• Discuss the role of the NP in your state, re:scope of practice, autonomy, education.
2
Critically analyze how healthcare systems and APN practice are organized and influenced by ethical, legal, economic and political factors. (PO 4)
Weekly Objectives
• Identify scope of practice that is specific to individual states.
• Apply current work experience to the APN roles.
Week 1: Summary and Planning Ahead
Summary
In week 1, we got to know a bit more about each other, the state you will practice in after
graduation and specifics with regards to NP practice. You will find it interesting how different the rules and regulations are very different state by state. You will be exploring this in much greater detail with your weeks 6 & 7 assignments.
Key Points
• Understood the diversity of your fellow students!
• Began to understand the LACE document located in the course and how it pertains to NP practice in your state.
• In weeks 6 & 7, you will need this information in order to complete the Professional Development Plan and recorded LACE presentation.
Planning Ahead
During WEEK 2 you will take a closer look at all 4 APN roles in your state. You will also discuss work environment, level of accountability, patient population, salary, and scope of practice for each of the APN roles. You will provide your personal Pro and Con list for each role and provide appropriate citations.
You will also describe your rationale for choosing the CNP advanced practice role versus any of the other three and your plans for clinical practice after graduation. You will decide if your idea of NP practice has changed after researching this for your state.
Open up week's 6 & 7 assignments and begin to understand the requirements for those two lengthy assignments [Show Less]