NSG6006 FULL STUDY GUIDE with 80 Questions and Answers
Policies and Practice Standards – State Nurse Practice Act
• _History and Developmental
... [Show More] Aspects of Advanced Practice Nursing
• Definition of advanced practice nurse (APN) - A nurse who has completed an accredited graduate-level education program preparing her or him for the role of certified nurse practitioner, certified registered nurse anesthetist, certified nurse-midwife, or clinical nurse specialist; has passed a national certification examination that measures the APRN role and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN involves advanced nursing knowledge and skills; it is not a medical practice, although APNs perform expanded medical therapeutics in many roles
• History of APN movement
History and evolution of nursing science Knowledge development
APN Roles
CNSs have a strong and tumultuous history. Over the past 20 years, the departure from direct patient care as being a main focus to working predominantly in the nursing education and systems improvement domains has created confusion within nursing and the public because non- CNSs (e.g., nurse educators, quality improvement managers) function in the same capacity.
However, CNSs are uniquely educated to provide advanced practice and specialist expertise when working directly with complex and vulnerable patients, educating and supporting interdisciplinary staff, and facilitating change and innovation in health care systems that those in other roles in health care cannot. As health care reform continues to gain momentum to improve the health care system, there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can develop new roles to meet the needs of patients and health care systems. For example, in nurse- managed clinics, perhaps NPs could deliver the primary care to patients in the management of hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a referral could be placed to the cardiovascular CNS for specialized pharmacologic and nonpharmacological treatment. Also, the cardiovascular CNS could integrate the latest evidence to create educational materials for patients and other health care professionals. Perhaps a CNM who is caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech position could ask the perinatal CNS to commonage the patient by following the patient and fetus or neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal CNS could establish interagency processes to facilitate care delivery across practice settings to provide seamless transitions of care. The possibilities are endless if CNSs understand their role, improve understanding of the importance of this role in advanced practice nursing, and maximize the driving forces and minimize the restraining forces in the health care system.
Primary care is the foundation of the evolving U.S. health care system. If access to primary care for all is the goal, while containing costs and focusing on quality outcomes, then NPs will be crucial to achieving these aims. In our current system, there just aren't enough PCPs to meet the need and, with an additional estimated 32 million more people who will be covered and need access to full primary care, based on the PPACA, we will need additional providers more than ever.
Physicians are not choosing primary care practice for complex reasons. On the other hand, most NPs choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these programs specifically to provide primary care. Two areas in particular must be addressed before NPs will be able to contribute fully to primary care delivery nationwide:
1. There must be changes in the outdated state scope of practice laws and regulations of nurse practitioners. This is because the variation in state regulations on scope of practice and prescribing authority has been a major barrier to using NPs fully and providing increased access to quality, cost-efficient primary care.
2. There must be substantive changes in health professional education to foster true collaboration and teamwork among physicians, NPs, and other health care disciplines in general to obtain the full benefit of diverse competencies inherent in a team.
If both of these are addressed, meeting U.S. primary care needs could be significantly affected in a positive way. Today's NP students and graduates must accept the professional responsibility for being active in the governance of delivery systems and informing and changing policy. There is too much at stake to leave this to a few, or to someone else. The health of the United States population depends on new models of care, on all health care providers practicing to the fullest extent of their education and training, and on strong teams who respect each other and partner with patients. NPs must support their efforts as they take an active role in developing stable health care policy and care delivery systems that allow for patient access to primary care services provided by NPs.
The ACNP role provides an opportunity for NPs to have a significant impact on patient outcomes at a dynamic time in the history of health care delivery. As their role continues to evolve, and as health care systems respond to market forces and economic change, opportunities to develop the ACNP role further will arise. Future development of the ACNP role should be based on the evaluation of the need for the role, understanding the scope of the role, assessment of the practice or organization, and the service needs of the patient population. Ensuring that ACNPs practice to the full scope of
(2011). Because the ACNP role continues to evolve, participation in national organizations to refine consensus regarding role components, program curriculum, marketing, and role evaluation is necessary. ACNP educators and clinicians must work together to ensure that the preparation and practice of ACNPs is safe, effective, and fully represented as the movement of doctoral APN education evolves. ACNPs must be strong activists in efforts to gain full recognition of their role within their proper scope of practice across acute care settings. In this evolving health care arena, ACNP practice is rapidly expanding and holds unlimited potential. Ongoing challenges include ensuring expansion of the ACNP with a focus on advanced practice nursing, rather than as a physician replacement model of care.
Nurse-midwifery practice encompasses a full range of primary health care services for women, from adolescence beyond menopause. These services include the independent provision of primary care, gynecologic and family planning services, preconception care, pregnancy care, childbirth and the postpartum period, care of the normal newborn during the first 28 days of life, and treatment of male partners for sexually transmitted infections. CNMs provide initial and ongoing comprehensive assessment, diagnosis, and treatment. They conduct physical examinations, prescribe medications, including controlled substances and contraceptive methods, admit, manage, and discharge patients from birth centers or hospitals, order and interpret laboratory and diagnostic tests, and order the use of medical devices. CNMs' care also includes health promotion, disease prevention, and individualized wellness education and counseling. CNMs must demonstrate that they meet the core competencies for basic midwifery practice of the ACNM (ACNM, 2008b) and must practice in accordance with the ACNM standards for the practice of midwifery (ACNM, 2011d). With constant changes in health care, CNMs may need to expand their knowledge and skills beyond that of basic CNM practice. Advanced CNM skills, such as level 1 ultrasound or acting as first assistant in surgery, may be incorporated into a CNM's practice as long as the CNM follows the recommendations for acquiring these skills by obtaining formal didactic and clinical training to ensure that the advanced skill is acquired and monitored to ensure patient safety.
There have been many recent positive advances in nurse-midwifery and between nurse-midwifery and the broader health care system. The ACNM has been reaching out to professional nursing, midwifery, medical, policy, and public health colleagues nationally and internationally. There has been international recognition of the need for more midwives to reduce maternal and neonatal mortality. In the United States, the IOM report, the Future of Nursing, and passage of the PPACA has placed CNMs and other APRNs in a partnership role in redesigning the health care system for the future.
From a midwifery perspective, we hope that this system will honor women and offer them support in realizing the power that comes with the choice of a woman-centered health care system.
Nurse anesthesia, the earliest nursing specialty, was also the first nursing specialty to have standardized educational programs, a certification process, mandatory continuing education, and recertification. Nurse anesthetists have been involved in the development of anesthetic techniques along with physicians and engineers. CRNAs have been nursing leaders in obtaining third-party reimbursement for professional services and in coping with challenges such as the prospective payment system, managed care, and physician supervision. Nurse anesthetists provide surgical and
nonsurgical anesthesia services in a variety of settings in the United States and other parts of the world. CRNAs work collaboratively with physicians, as do other APNs, and are capable of providing the full spectrum of anesthesia services. Activism at the state and federal legislative and regulatory levels is a recognized CRNA activity. Increasing coalition building among nurse anesthetists, other APNs, and nursing educators is congruent with a shared nursing vision. This vision values health care for all Americans, provided in a safe and cost-effective manner by APNs collaborating with other health care professionals. John F. Garde was a distinguished health care leader who served as AANA Executive Director from 1983 to 2001, and again on an interim basis from February 2009 until his untimely death in July 2009. A statement of his holds true today (Garde, 1998, p. 15): The profession has an optimistic future. I point out with pride the commitment that AANA members have toward the future of their profession—a commitment that encompasses being outstanding anesthesia practitioners who belong to their Association. I am reminded, too, what Dick Davidson, President of the American Hospital Association, said when asked about what will remain in health care 100 years from now: ‘There will always be personal contact and caring. We will always have hands touching patients. Everything we do is about human need. That's the constant over time.’ And, that is the legacy of the nurse anesthesia profession.
SCOPE OF PRACTICE
scope of practice describes practice limits and sets the parameters within which nurses in the various advanced practice nursing specialties may legally practice. Scope statements define what APRNs can do for and with patients, what they can delegate, and when collaboration with others is required. Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S. health care system uses APRNs as health care providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice markedly different from that of the primary care nurse practitioner (NP), for example, although both have their roots in basic nursing. In addition, it is important to understand that scope of practice differs among states and is based on state laws promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo, O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of practice statements can be found by searching state government websites in the areas of licensing boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site (www.ncsbn.org). Recent federal policy initiatives, including the IOM Future of Nursing Report, (2011). the PPACA (HHS, 2011), and the Josiah Macy Foundation (Cronenwett & Dzau, 2010) have all issued recom mendations with important implications for expanding the scope of practice for APRNs. The National Health Policy Forum (http://www.nhpf.org/library/background- papers/BP76_SOP_07-06-2010.pdf) and Citizen Advocacy Center (https://www.ncsbn.org/ReformingScopesofPractice-WhitePaper.pdf) reports state firmly that current scope of practice adjudication is far too technical, subject to political pressure, and therefore not appropriate in the legislative sphere. There must be a more powerful forum so that the public can enter into the dialogue (see Chapter 22). As scope of practice expands, accountability becomes a crucial factor as APRNs obtain more authority over their own practices. First, it is important that scope of practice statements identify the legal parameters of each APRN role. Furthermore, it is crucial that scope of practice statements presented by national certifying entities are carried through in language in state statutes (Buppert, 2012). Our society is highly mobile and APRNs must recognize that their scope of practice will vary among states; in a worst case scenario, one can be an APRN in one state but not meet the criteria in another state.
1. Throughout the century, APNs have been permitted by organized medicine and state legislative bodies to provide care to the underserved poor, particularly in rural areas of the nation. However, when that care competes with physicians' reimbursement for their services, there has been significant resistance from organized medicine, which resulted in interprofessional conflict.
2. Documentation of the outcomes of practice helped establish the earliest nursing specialties and continues to be of critical importance to the survival of APN practice.
3. The efforts of national professional organizations, national certification, and the move toward graduate education as a requirement for advanced practice have been critical to enhancing the credibility of advanced practice nursing.
4. Intraprofessional and interprofessional resistance to expanding the boundaries of the nursing discipline continue to recur.
5. Societal forces, including wars, the economic climate, and health care policy, have influenced APN history.
• _Scope of practice cont.
The term scope of practice refers to the legal authority granted to a professional to provide and be reimbursed for health care services. The ANA (2010) defined the scope of nursing practice as “The description of the who, what, where, when, why, and how of nursing practice.” This authority for practice emanates from many sources, such as state and federal laws and regulations, the profession's code of ethics, and professional practice standards. For all health care professionals, scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes are the nurse practice acts of the various states. As previously discussed, APN scope of practice is characterized by specialization, expansion of services provided, including diagnosing and prescribing, and autonomy to practice (NCSBN, 2008). The scopes of practice also differ among the various APN roles; various APN organizations have provided detailed and specific descriptions for their particular role. Carving out an adequate scope of APN practice authority has been an historic struggle for most of the advanced practice groups (see Chapter 1) and this continues to be a hotly debated issue among and within the health professions. Significant variability in state practice acts continues, such that APNs can perform certain activities in some states, notably prescribing certain medications and practicing without physician supervision, but may be constrained from performing these same activities in another state (Lugo, O'Grady, Hodnicki, & Hanson, 2007).
The Consensus Model's proposed regulatory language can be used by states to achieve consistent scope of practice language and standardized APRN regulation (NCSBN, 2008).
A scope of practice is a state-based legal framework (i.e., statutes, codes, and regulations) that defines who is authorized to provide clearly delineated services, to whom and under what circumstances those services can be provided, and who can be reimbursed for those services. All health professions have an autonomous domain of practice and a delegated authority within the medical domain (Lyon, 2004). The autonomous domain of nursing practice “encompasses the diagnosis of health conditions (e.g., nursing diagnoses) that are amenable to nursing interventions [and] therapeutics, the implementation of interventions, and evaluation of the effectiveness of nursing interventions [and] therapeutics” (Lyon, 2004, p. 9). Historically, the medical profession developed a broad, overarching scope of practice that encompassed almost all health care activities (see Chapter 1; Safriet, 2010). As a consequence, other health professionals (e.g., nurses, physical therapists, pharmacists) have had to carve out their scopes of practice out of the medical scope of practice. The ANA's restrictive 1955 definition of nursing reinforced the practice of nursing as having independent functions and being dependent on and delegated to by the profession of medicine. It also prohibited nurses from diagnosing and prescribing.
By definition, the term scope of practice describes practice limits and sets the parameters within which nurses in the various advanced practice nursing specialties may legally practice. Scope statements define what APRNs can do for and with patients, what they can delegate, and when collaboration with others is required. Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S. health care system uses APRNs as health care providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice markedly different from that of the primary care nurse practitioner (NP), for example, although both have their roots in basic nursing. In addition, it is important to understand that scope of practice differs among states and is based on state laws promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo, O'Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of practice statements can be found by searching state government websites in the areas of licensing boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site (www.ncsbn.org). Recent federal policy initiatives,
including the IOM Future of Nursing Report, (2011). the PPACA (HHS, 2011), and the Josiah Macy Foundation (Cronenwett & Dzau, 2010) have all issued recom mendations with important implications for expanding the scope of practice for APRNs. The National Health Policy Forum (http://www.nhpf.org/library/background-papers/BP76_SOP_07-06-2010.pdf) and Citizen Advocacy Center (https://www.ncsbn.org/ReformingScopesofPractice-WhitePaper.pdf) reports state firmly that current scope of practice adjudication is far too technical, subject to political pressure, and therefore not appropriate in the legislative sphere. There must be a more powerful forum so that the public can enter into the dialogue (see Chapter 22). As scope of practice expands, accountability becomes a crucial factor as APRNs obtain more authority over their own practices. First, it is important that scope of practice statements identify the legal parameters of each APRN role. Furthermore, it is crucial that scope of practice statements presented by national certifying entities are carried through in language in state statutes (Buppert, 2012). Our society is highly mobile and APRNs must recognize that their scope of practice will vary among states; in a worst case scenario, one can be an APRN in one state but not meet the criteria in another state (Minnesota Nursing, 2011; Taylor, 2006)
• _Evolution of the APN role
CRNA 1945, Mid Wife 1955, PNP 1965, 1979 DN, 1985 NP, 1995 CNS
• _Four recognized APN roles
o Clinical nurse specialist -1995
Key to their development in the 1940s was the establishment of a formal organization of practicing nurse-midwives, the American Association of Nurse-Midwives (AANM), which incorporated in 1941 under the leadership of Mary Breckinridge. By July 1942, the AANM had a “membership of 71 graduate nurses” who had specialty training in midwifery (News Here and There, 1942, p. 832).
Three years later, in 1944, the National Organization of Public Health Nurses established a section for nurse-midwives within their organization. This group prepared a roster of all midwives in the country and defined their practice, making it clear that nurse-midwives would continue to practice under physician authority.
By the middle of the 1970s, the ANA officially recognized the CNS role, defining the CNS as an expert practitioner and change agent. Of particular significance, the ANA's definition specified a master's degree as a requirement for the CNS (ANA Congress of Nursing Practice, 1974). As with the other advanced nursing specialties, the development of the CNS role included early evaluation research that served to validate and promote the innovation. Georgopoulos and colleagues (Georgopoulos & Christman, 1970; Georgopoulos & Jackson, 1970; Georgopoulos & Sana, 1971) conducted studies evaluating the effect of CNS practice on nursing process and outcomes in inpatient adult health care settings. These and other evaluative studies (Ayers, 1971; Girouard, 1978; Little & Carnevali, 1967) demonstrated the positive effect of the CNS on improving nursing care and patient outcomes. Moreover, with the increasing demand from society to cure illness using the latest scientific and technologic advances, hospital administrators willingly supported specialization in nursing and hired CNSs, particularly in the revenue-producing ICUs. Box 1-5 presents more information on the growth and development of nursing in the 1970s.
this group of health care leaders was charged with evaluating the feasibility of expanding nursing practice (Kalisch & Kalisch, 1986). They concluded that extending the scope of the nurse's role was essential to providing equal access to health care for all Americans. According to an editorial in the AJN, “The kind of health care Lillian Wald began preaching and practicing in 1893 is the kind the people of this country are still crying for” (Schutt, 1971, p. 53). The committee urged the establishment of innovative curricular designs in health science centers and increased financial support for nursing education. It also advocated standardizing nursing licensure and national certification and developed a model nurse practice law suitable for national application. In addition, the committee called for further research related to cost-benefit analyses and attitudinal surveys to assess the impact of the NP role (HEW, 1972). This report resulted in increased federal support for training programs for the preparation of several types of NPs, including family NPs, adult NPs, and emergency department NPs.
he 1960s are most often noted as the decade in which clinical nurse specialization took its modern form. Peplau (1965) contended that the development of areas of specialization is preceded by three social forces: (1) an increase in specialty-related information; (2) new technologic advances; and (3) a response to public need and interest. In addition to shaping most nursing specialties, these forces had a particularly strong effect on the development of the psychiatric CNS role in the 1960s. The Community Mental Health Centers Act of 1963, as well as the growing interest in child and adolescent mental health care, directly enhanced the expansion of that role in outpatient mental health care.
CNSs have a strong and tumultuous history. Over the past 20 years, the departure from direct patient care as being a main focus to working predominantly in the nursing education and systems improvement domains has created confusion within nursing and the public because non-CNSs (e.g., nurse educators, quality improvement managers) function in the same capacity. However, CNSs are uniquely educated to provide advanced practice and specialist expertise when working directly with complex and vulnerable patients, educating and supporting interdisciplinary staff, and facilitating change and innovation in health care systems that those in other roles in health care cannot. As health care reform continues to gain momentum to improve the health care system, there will be many new opportunities for CNSs. As masters of flexibility and creativity, CNSs can develop new roles to meet the needs of patients and health care systems. For example, in nurse- managed clinics, perhaps NPs could deliver the primary care to patients in the management of hypertension. Once first- or second-line therapies or interventions are found to be ineffective, a referral could be placed to the cardiovascular CNS for specialized pharmacologic and nonpharmacologic treatment. Also, the cardiovascular CNS could integrate the latest evidence to create educational materials for patients and other health care professionals. Perhaps a CNM who is caring for a pregnant woman who develops gestational diabetes, preeclampsia, and is in breech position could ask the perinatal CNS to comanage the patient by following the patient and fetus or neonate in the prenatal setting through hospital discharge into the postpartum phase. The perinatal CNS could establish interagency processes to facilitate care delivery across practice settings to provide seamless transitions of care. The possibilities are endless if CNSs understand their role, improve understanding of the importance of this role in advanced practice nursing, and maximize the driving forces and minimize the restraining forces in the health care system.
o Nurse practitioner (primary care; acute care) 1985
The idea of using nurses to provide what we now refer to as primary care services dates to the late nineteenth century. During this period of rapid industrialization and social reform, public health nurses played a major role in providing care for poverty-stricken immigrants in cities throughout the country. In 1893, Lillian Wald, a young graduate nurse from the New York Training School for Nurses, established the Henry Street Settlement (HSS) House on the Lower East Side of Manhattan. Its purpose was to address the needs of the poor, many of whom lived in overcrowded, rat-infested tenements. For several decades, the HSS visiting nurses, like other district nurses, visited thousands of patients with little interference in their work (Wald, 1922). The needs of this disadvantaged community were limitless. According to one account (Duffus, 1938):
most NPs choose primary care practice roles (e.g., family, adult, and pediatric NPs) because they enter these programs specifically to provide primary care.
As with other advanced practice roles, direct clinical practice is the foundation of the work of the primary care NP, which unfolds around the premise that individuals seek care for a broad range of health care concerns over time and across the life span. Relationships evolve over time, which facilitates a sense of mutual respect and trust. In that relationship, a deep understanding of the patient's life and the meaning of the illness or health issue at hand develops. Knowing patients and their family members, their jobs and careers, and their challenges in raising children and caring for aging parents is part of accompanying patients through the transitions of life
it was during the 1960s that the role was first described formally and implemented in outpatient pediatric clinics, originating in part as a response to a shortage of primary care physicians. As the trend toward medical specializa [Show Less]