A framework for advanced practice nursing

What is nursing in advanced nursing practice? Applying theories and models to advanced nursing practice-A discursive review

AIM

This article appraises models and theories related to advanced nursing practice. It argues that while the role of the advanced nurse practitioner builds on and extends beyond traditional nursing, it remains firmly grounded in 'caring'.

BACKGROUND

The stereotype that nurses 'care' and doctors 'cure' is fading. Increasingly, nurses have crossed boundaries and conducted independent assessment, diagnosis, prescribing and consultation, which used to be the doctor's role. Confusion and argument have arisen due to the higher-level practice of the advanced nurse practitioner, as many questions where these 'doctor nurses' stand.

DESIGN

A literature review.

DATA SOURCES

Databases, including CINAHL, Medline and Google Scholar, were searched.

METHOD

Databases were searched, and relevant studies and review articles from 1970 to 2023 were identified using the following keywords: 'advanced nurse practitioner', 'nurse practitioner', 'advanced nursing', 'advance practice', 'nurse practitioner', 'nursing theory' and 'nursing model'.

RESULTS

Although advanced nurse practitioners identify themselves as nurses, there is limited use of nursing theory to conceptualize this new level of practice and to define their contribution to the multi-disciplinary team. It is noted that a holistic approach to personalized patient care, based on therapeutic relationships and effective communication, may help us identify the unique contribution of the advanced nurse practitioner.

CONCLUSIONS

The development of advanced nursing theory needs to capture this holistic approach and its caring element to recognize the value and strengthen the identity allegiance of this hybrid role.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Holistic approach and patient-centred care, effective communication and the therapeutic relationship are strong characteristics relating to ANP practice, the latter of which is yet to be clearly defined and captured in nursing theories. Conceptualizing ANP practice and capturing their valuable nursing care will enable better understanding and clarity for the role to realize its full potential.

Alignment of the International Council of Nurses Advanced Practice Nursing Guideline Characteristics With Conceptual Frameworks: A Scoping Review

Background: During the past 50 years, numerous conceptual frameworks have been used to describe and evaluate advanced practice nursing (APN) roles and outcomes. The International Council of Nurses (ICN) released an updated description of APN characteristics intersecting with currently utilized frameworks allows for assessing relevance to practice. Purpose: The review aimed to examine the alignment of established and commonly used conceptual frameworks related to advanced practice roles with the ICN APN guidelines characteristics. This will help identify a globally relevant framework for APN roles. Method: PubMed, Cumulative Index in Nursing and Allied Health Literature, and ProQuest Central databases were searched using terms that characterize APN and conceptual frameworks. To address currency and relevance of frameworks was applied to discovered frameworks identifying and reviewing in detail those which were cited more than 15 times during the last five years. Results: This search found over 1107 publications. Of these, nine conceptual frameworks met all inclusion criteria. The frameworks captured some of the characteristics described by the ICN. Eight addressed all categories but in a limited fashion. Implications for Practice: Reviewing recently and frequently cited frameworks can inform the applicability in the interested readers, own nursing practice. This review not only does this but also examines the global uptake and the relationship to international standards of APN to provide additional information on the frameworks' reach and worldwide transferability. However, further research examining the relevance of these frameworks in low- and lower-middle-income countries is needed to understand their importance.

Advancing the case for nurse practitioner-based models to accelerate scale-up of HIV pre-exposure prophylaxis

AIMS

To explore the factors that position nurse practitioners (NPs) to lead the implementation of HIV pre-exposure prophylaxis.

BACKGROUND

The HIV epidemic represents a global health crisis. Reducing new HIV infections is a public health priority, especially for Black and Latino men who have sex with men (MSM). When taken as directed, co-formulated emtricitabine and tenofovir have over 95% efficacy in preventing HIV; however, substantial gaps remain between those who would benefit from pre-exposure prophylaxis (PrEP) and current PrEP prescribing practices.

DESIGN

This is a position paper that draws on concurrent assessments of research literature and advanced practice nursing frameworks.

METHOD

The arguments in this paper are grounded in the current literature on HIV PrEP implementation and evidence of the added value of nurse-based models in promoting health outcomes. The American Association of Colleges of Nursing's advanced nursing practice competencies were also included as a source of data for identifying and cross-referencing NP assets that align with HIV PrEP care continuum outcomes.

CONCLUSIONS

There are four main evidence-based arguments that can be used to advance policy-level and practice-level changes that harness the assets of nurse practitioners in accelerating the scale-up of HIV PrEP.

RELEVANCE TO CLINICAL PRACTICE

Global public health goals for HIV prevention cannot be achieved without the broader adoption of PrEP as a prevention practice among healthcare providers. NPs are the best hope for closing this gap in access for the populations that are most vulnerable to HIV infection.

Current State of Pain Resource Nurse (PRN) Programs and Experiences of PRNs in China

BACKGROUND

Since the 2010s, the Pain Resource Nurse (PRN) program and similar programs have been introduced in Chinese hospitals. However, the status of the PRN program and nurses' experiences in these programs remain unclear.

AIMS

The aim of the study was to identify the factors related to PRN programs and explore PRNs' experiences being part of the program.

DESIGN

A combination of descriptive cross-sectional and qualitative methods was used in the study.

SETTINGS

Thirty-two hospitals in the eastern, central, and western regions of China.

PARTICIPANTS/SUBJECTS

Twenty-four PRNs who had been PRNs for 6 months or more.

METHODS

A purposive sample of 32 hospitals from eastern, central, and western regions of China carried out a PRN or similar program for more than 1 year with at least five bedside nurses from different nursing units were enrolled in the descriptive cross-sectional study. The questionnaire was designed by Brown's advanced nursing practice framework theory. A total of 24 PRNs who had been PRNs for 6 months or more participated in the interview by convenience and purposive sampling.

RESULTS

The mean number of PRNs in a program was 30.12 ± 17.93 (range 5-74). The role of the PRN was broader compared with that of bedside nurses, and it included pain management, training, and education. The most common reason for hospitals to establish PRN programs was to improve the quality of pain management (n = 28, 87.5%). Administrative support (n = 28, 87.5%) was a major supportive factor for PRN programs and lack of physician support (n = 28, 87.5%) was a barrier. Although all hospitals provided training, those with knowledge assessments after training indicated a significant improvement in the desired PRN functions compared with those that did not (p < .05). Personal interviews revealed that the reasons for becoming a PRN varied and included considering PRN as a career opportunity, personal interest, passively accepting the designation, and being a PRN temporarily. The positive professional experiences of being a PRN included an increased sense of self-worth and accomplishment and growth in a specialty, whereas the negative experiences included frustration with the work environment and resignation because of extra workload.

CONCLUSIONS

The hospital survey results indicated that the PRN program in China is still in the early development stage. The PRN interviews suggest that being a PRN involves both positive and negative experiences.

IFNA approved Chinese Anaesthesia Nurse Education Program: A Delphi method

BACKGROUND

Numerous nurses work in operating rooms and recovery rooms or participate in the performance of anaesthesia in China. However, the scope of practice and the education for Chinese Anaesthesia Nurses is not standardized, varying from one geographic location to another. Furthermore, most nurses are not trained sufficiently to provide anaesthesia care.

OBJECTIVES

This study aimed to develop the first Anaesthesia Nurse Education Program in Mainland China based on the Educational Standards of the International Federation of Nurse Anaesthetists.

METHODS

The Delphi technique was applied to develop the scope of practice, competencies for Chinese Anaesthesia Nurses and education program. In 2014 the Anaesthesia Nurse Education Program established by the hospital applied for recognition by the International Federation of Nurse Anaesthetists. The Program's curriculum was evaluated against the IFNA Standards and recognition was awarded in 2015.

RESULTS

The four-category, 50-item practice scope, and the three-domain, 45-item competency list were identified for Chinese Anaesthesia Nurses. The education program, which was established based on the International Federation of Nurse Anaesthetists educational standards and Chinese context, included nine curriculum modules. In March 2015, 13 candidates received and passed the 21-month education program. The Anaesthesia Nurse Education Program became the first program approved by the International Federation of Nurse Anaesthetists in China.

CONCLUSIONS

Policy makers and hospital leaders can be confident that anaesthesia nurses graduating from this Chinese program will be prepared to demonstrate high level patient care as reflected in the recognition by IFNA of their adoption of international nurse anaesthesia education standards.

Advanced or advancing nursing practice: what is the future direction for nursing?

Advanced nursing practice roles have emerged over the last 25 years in response to two major challenges: first, the significant reduction in available doctors; and, second, the rise in numbers of patients with complex health needs. It is suggested that, with a major drive to respond to the first problem, with its emphasis on the development of medical skills, the development of advanced nursing practice (which has the potential to have a significant impact on the second challenge of the rise in long-term conditions) has very much taken second place. Moreover, advanced nursing practice roles have become so medically focused that not only is advanced nursing practice not evident, but neither are the recognised sub-roles that are fundamental to advancing practice. These include innovation, education, research and clinical leadership. This article argues that in the current climate it is essential that advanced nurse practitioners not only demonstrate advanced practice, but also actively embrace the concept of 'advancing' nursing practice as the dominant feature of new roles.

Experiences of working as an advanced practice nurse in Finland--the substance of advanced nursing practice and promoting and inhibiting factors

BACKGROUND

Evaluation of new advanced practice nursing roles, from different angles, is strongly recommended in the literature. New nurses' experiences of working in an advanced role may highlight problems and/or factors that promote or inhibit a successful implementation of new advanced nursing roles.

AIM

To explore advanced practice nurses' experiences of the content of their nursing care and to describe promoting or inhibiting factors for working with a full scope of advanced nursing practice.

METHODS

The study design was explorative and descriptive. A total of 24 advanced practice nurses participated in focus group interviews (two were interviewed individually) about the processes, structure and outcome of working as advanced practice nurses. Qualitative manifest content analysis was used for data analysis.

FINDINGS

The substance of advanced practice nursing can be described with three main themes: a broader and deeper holistic view of patients' state of health, an independent and responsible manner of working and knowing own limits. Promoting factors were an identity as a nurse with advanced competency, feedback from satisfied patients and fruitful teamwork is a necessity. Inhibiting factors were a lack of organisational understanding for advanced nursing practice, poor planning leads to unsatisfactory advanced practice nursing models and advanced practice nurses' lack of courage in adopting new advanced roles.

CONCLUSION

The participants experienced both a personal inner transition and a role transition that were either supported or opposed. Vague or nonexistent definitions and concepts, insufficient knowledge, insufficient support and undefined roles hindered participants' role transition. Two main strategies should be employed. The first is the realisation of more strategic leadership and support from organisations on all management levels, including nursing organisations/unions, while the second is to more realistically prepare future advanced practice nurses for the challenges they will face, through mentorship programmes and continuous further training.

Identifying components of advanced-level clinical nutrition practice: a Delphi study

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a master's degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

Advanced practice nursing for enduring health needs management: a global perspective

Advanced practice nursing expertise has been acknowledged worldwide as one response to the challenges arising from changes in society and health care. The roots of advanced practice nursing education are at the University of Colorado where the first known programme started in 1965. In many countries advanced practice nurses (APNs) have taken responsibility for routine patient care formerly carried out by physicians in order to reduce their workload. However, more and more, APNs have taken responsibility for new service areas and quality programmes not previously provided. Chronic disease management is one of these new service areas because long-term diseases are increasingly challenging service systems globally. This article is based on an international APN partnership. The aim of the article is to describe how the partnership will design a 15 ECTS credit course on Enduring Health Need Management as a cross-cultural collaborative endeavour. The adaptation of an inquiry based learning framework will be described drawing on four main principles of the theory: authentic learning communities; student encouragement in analysing gradually more complicated problems; networking in knowledge creation and; student engagement and activity. The cross-cultural online course aims to increase APNs' intercultural competence as well as their global and international work orientation.

Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness

AIM

This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness.

BACKGROUND

Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed.

DATA SOURCES

Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009.

DISCUSSION

A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance.

IMPLICATIONS FOR NURSING

The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners.

CONCLUSION

The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams.

Specialty and Advanced Practice Nursing

Advanced practice nursing and specialty practice are terms that are often used interchangeably in nursing discourse. This column explores the inextricable link, as well as the differences between these two types of practice. Drawing differing conclusions about their specific and cooperative value enables nurses to construct innovative and creative approaches to their continued development that illuminates a path for disciplinary expansion. Congruent programs of education prepare nurses to communicate the distinctiveness of their many and varied contributions to the public with greater clarity and emphatic certainty.

A Definition, Description, and Framework For Advanced Practice in Dietetics

Purpose: We explored advanced practice (AP) across the diversity of dietetics to develop a definition, description, and framework for guiding future education, research agendas, and policy development.

Methods: The process began with a literature review and discussion with dietitians exploring AP in other countries. Various concepts were identified, and these informed the phase 1 survey questions. Phase 1 was a 36-item survey created in SurveyMonkey, engaging a purposeful sample of key stakeholders (n=136). A modified Delphi approach, involving seven dietitians from different geographical locations and practice areas, finalized the phase 2 survey. An e-mail link to this 50-item survey was sent to a random sample of dietitians (n=885). The proposed AP framework entailed an iterative approach, integrating survey results with AP literature.

Results: Response rates were 40% for phase 1 and 35% for phase 2. In phase 1, 83% of respondents agreed that a depth and breadth definition captured all dietetic job roles, and 95% agreed that it differentiated AP from entry-level practice. Descriptive statistics are presented to provide demographic information and level of agreement with themes relevant to AP.

Conclusions: A framework is presented, and discrepancies with phase 2 results indicate areas for professional development, such as leadership, mentorship, and outcome measurement.

The Connected Learning Model for disseminating evidence-based care practices in clinical settings

Clinical practice guidelines have been developed to improve patient care and outcomes. Guideline implementation is often stymied by the complexity of patients' conditions, complex care environments, and limited advanced clinical training of nursing staff. To translate key elements of heart failure guidelines into practice in a nursing home, the Connected Learning Model was developed based on the diffusion of innovations framework. An advanced practice nurse in geriatrics fostered greater interaction and collaboration among key administrative, medical, and nursing staff to promote awareness of heart failure guidelines and to translate key practices from those guidelines into the nursing home setting. Direct care staff skills for early recognition and reporting of signs and symptoms of acute heart failure were enhanced through a learner-centered educational program which included classroom and unit-based instruction and bedside clinical teaching. The Connected Learning Model is a promising method to mobilize advanced nursing expertise to bridge research/practice gaps through implementation of clinical practice guidelines that are systematically adapted to accommodate diverse health care contexts.

Advancing practice in critical care: a model of knowledge integration

AIM

The aim of this paper was to discuss the potential development of a conceptual model of knowledge integration pertinent to critical care nursing practice. A review of the literature identified that reflective practice appeared to be at the forefront of professional development.

BACKGROUND

It could be argued that advancing practice in critical care has been superseded by the advanced practice agenda. Some would suggest that advancing practice is focused on the core attributes of an individual's practice, which then leads onto advanced practice status. However, advancing practice is more of a process than identifiable skills and as such is often negated when viewing the development of practitioners to the advanced practice level. For example, practice development initiatives can be seen as advancing practice for the masses, which ensures that practitioners are following the same level and practice of care. The question here is, are they developing individually?

RELEVANCE TO CLINICAL PRACTICE

What this paper presents is that reflection may not be best suited to advancing practice if the individual practitioner does not have a sound knowledge base both theoretically and experientially. The knowledge integration model presented in this study uses multiple learning strategies that are focused in practice to develop practice, e.g. the use of work-based learning and clinical supervision. To demonstrate the models application, an exemplar of an issue from practice shows its relevance from a practical perspective.

CONCLUSIONS

In conclusion, further knowledge acquisition and its relationship with previously held theory and experience will enable individual practitioners to advance their own practice as well as being a resource for others.

Making nursing work: breaking through the role confusion of advanced practice nursing

AIM

This paper reports a study to develop a research-informed model of the service parameters and an analysis framework for advanced practice nursing roles.

BACKGROUND

Changing patterns of health care are forcing service planners to examine new service delivery models. Apparent is the call for nursing service that incorporates expanded levels of autonomy, skill and decision-making. A number of nursing roles conform to this description under the generic title of advanced practice nurse. However, there is confusion in the health service community internationally about nomenclature, role and scope for advanced practice nursing roles. An emerging priority in response to recent developments in the nurse practitioner role is to establish service parameters for advanced practice nursing and to differentiate operationally between advanced practice and practitioner nursing roles.

METHODS

We conducted an interpretive, qualitative examination of the practice of a random sample of nine advanced practice nurses working in three acute care hospitals in south east Queensland, Australia in 2006. Data collection involved individual in-depth interviews, which were deductively analysed and tested against published advanced practice nursing models.

RESULTS

The data most comprehensively supported the Strong Model of Advanced Practice as representing the practice experiences of the research participants. This model supports definition of the service parameters and the design of an operational framework for implementation and evaluation of advanced practice nursing roles.

CONCLUSION

The findings differentiate advanced practice nurse and nurse practitioner roles, and offer an operational framework to identify, establish and evaluate advanced and extended nursing positions. Subject to further validation, this outcome can provide operational information for implementing innovative nursing roles appropriate to consumer needs and specific health service models.

Outcomes of Scholarly Inquiry: An Analysis of Master's of Nursing Students' Projects/Theses

This study examined the first scholarly projects/theses of 112 graduates of a newly formed Master of Nursing (MN) program. The purpose of the analysis was to determine whether MN graduates' scholarly projects/theses addressed the American Association Colleges of Nursing's (1996) Essentials of Master's Education for Advanced Practice Nursing, met program outcomes, and adhered to campus and program values. Other specific questions were formulated to ascertain the method of inquiry most used, the population group most examined, and the outcomes of the inquiry. The sample of 106 scholarly projects and six theses were categorized according to method of inquiry, population group, population type, and scholarly outcomes and then entered into a database software program. The findings showed the method of inquiry most used was literature review, followed by program critique, community assessment, and secondary analysis. The community was the most frequently examined population group, with patient, children, provider, minority, and elderly the most used population type. The most frequent scholarly outcomes were recommendations, study reports, educational materials, and program development. Findings supported the campus's and program's mission statement that values community partnership and diversity, improved health care outcomes, as well as an outcome objective of master's-level proficiencies in research competencies.

Using Initiative to Achieve Autonomy: A Model for Advanced Practice in Medical Nutrition Therapy

The purpose of this research was to generate a model of advanced medical nutrition therapy (MNT) practice based on descriptions of their clinical activities provided by advanced-level MNT practitioners. A qualitative approach using grounded theory methodology was employed. The model of advanced MNT practice was based on interviews with 21 credentialed advanced practice registered dietitians from across the United States and Canada. Verbatim transcripts of the interviews were coded for aggregation into themes and subthemes. The resulting model included a single overarching theme: using initiative to achieve autonomy. The five subthemes are aptitude, attitude, expertise, context, and approach. The model provides a richer picture of advanced MNT practice than was previously available and is presented for discussion and debate. Validation of the model is required before incorporation into education or practice.

Advanced practice nursing roles: development, implementation and evaluation

AIM

The aim of this paper is to discuss six issues influencing the introduction of advanced practice nursing (APN) roles: confusion about APN terminology, failure to define clearly the roles and goals, role emphasis on physician replacement/support, underutilization of all APN role domains, failure to address environmental factors that undermine the roles, and limited use of evidence-based approaches to guide their development, implementation and evaluation.

BACKGROUND

Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. The extent to which these roles truly reflect advanced nursing practice is often unclear. The misuse of APN terminology, inconsistent titling and educational preparation, and misguided interpretations regarding the purpose of these roles pose barriers to realizing their full potential and impact on health. Role conflict, role overload, and variable stakeholder acceptance are frequently reported problems associated with the introduction of APN roles.

DISCUSSION

Challenges associated with the introduction of APN roles suggests that greater attention to and consistent use of the terms of the terms advanced nursing practice, advancement and advanced practice nursing is required. Advanced nursing practice refers to the work or what nurses do in the role and is important for defining the specific nature and goals for introducing new APN roles. The concept of advancement further defines the multi-dimensional scope and mandate of advanced nursing practice and distinguishes differences from other types of nursing roles. Advanced practice nursing refers to the whole field, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place.

CONCLUSIONS

Recommendations for the future introduction of APN roles can be drawn from this paper. These include the need for a collaborative, systematic and evidence-based process designed to provide data to support the need and goals for a clearly defined APN role, support a nursing orientation to advanced practice, promote full utilization of all the role domains, create environments that support role development, and provide ongoing evaluation of these roles related to predetermined goals.

Characteristics and role functions of advanced practice nurses in a tertiary pediatric setting

ISSUES AND PURPOSE

To describe the characteristics and role functions of Advanced Practice Nurses (APNs) in a tertiary pediatric setting.

DESIGN AND METHODS

This descriptive survey design used a convenience sample (N = 39) of APNs at The Children's Hospital in Denver. A 56-item survey asked participants to define their role by rating how often they performed various primary and specialty care functions.

RESULTS

Findings validated the notion that APNs combine expert knowledge and practice skills into a holistic framework to provide sick children and their families with a full range of comprehensive services across a variety of settings. APNs work collaboratively with physicians and other professionals and are an excellent resource for students.

PRACTICE IMPLICATIONS

Describing and characterizing how APNs contribute to and enhance the delivery of care help to clarify and authenticate the scope of practice of the pediatric acute care APN.

A framework for the introduction and evaluation of advanced practice nursing roles

AIM

This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework).

BACKGROUND

Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework.

CONCLUSIONS

The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.

Advanced practice nursing model for comprehensive care with chronic illness: model for promoting process engagement

New models of providing care to chronically ill persons are needed that can facilitate a more integrative approach to patient care. The purposes of this article are to describe the utilization of a theory synthesis process for development of a client-focused approach for advanced practice nurse (APN) management of chronic illness and to present the Model for Promoting Process Engagement. The model was developed as a theory-driven intervention to address complexities of chronic illness care. This APN practice model is the direct result of the synthesis of a number of differing theoretical models developed by the authors in previous individual research endeavors.

Evaluations of clinical learning in a managed care environment

TOPIC

Clinical learning in a managed-care environment.

PURPOSE

To obtain evaluative data about clinical learning experiences for graduate nursing students based on the domains of competence for successful practice in managed-care organizations.

METHODS

A survey of 42 nurses (20 graduate students, 22 nurse practitioner preceptors) self-reported on two questionnaires.

FINDINGS

Both the students and preceptors reported that there were learning opportunities for research utilization, the development of clinical competence, the identification of group dynamics, the development of leadership skills. In addition, the respondents reported learning opportunities to examine the financial impact on healthcare delivery and clinician decision making. The area of ethics and its impact on clinical decision making is an apparent void, as reported by the respondents.

CONCLUSIONS

A managed care environment does provide an effective learning environment for nurse practitioner students.

Asthma care by nurse practitioners in the United States

PURPOSE

To survey nurse practitioners (NPs) in the United States on their level of input to asthma care prior to enrolling in The National Asthma and Respiratory Training Centre (NARTC) specialist asthma education program in the UK.

DATA SOURCES

Responses of 134 (66%) of the 202 NPs who self-selected for enrollment in the NARTC program on a preliminary questionnaire.

CONCLUSIONS

Nearly all (133 or 99%) currently work with asthmatics and 122 (91%) prescribe asthma drugs. Only 92 (69%) measure peak flow(PF), 84 (63%) check inhaler technique, 76 (57%) teach use of a home PF meter and diary, and 63 (47%) provide written self-management plans on any regular basis. Many have not established follow-up procedures (56 or 42%), or evaluated their asthma management practices (55 or 41%).

IMPLICATIONS FOR PRACTICE

Successful asthma management requires correct medication, systematic follow-up, patient education, and self-management. Specialist asthma training should encourage practitioners to combine effective drug usage with a long-term preventative approach.

Postgraduate education for nurses: the Middlesex model

Nurse education has been subject to many changes and much debate and criticism over recent years. What has become increasingly evident is that with the changing nature of nursing within society, nursing curricula have to be more flexible and dynamic if they are to meet a multiplicity of needs. There is also a need to recognize that many levels of curricula will be required to prepare the nurses of the future. At Middlesex University the development of specialist practice programmes at postgraduate diploma level, and preparation of nurses for a higher level of practice at masters level has required the development of a new curriculum model which allows both the individualization of academic programmes to meet the needs of nurses, their clients and the organization in which they work, and the integration of development and learning through practice. This model is built on the results of an evaluation of an existing postgraduate programme in interprofessional health care. Key features of the curriculum development include a structured collaboration between student, practice mentor and academic supervisor, and the use of a professional development portfolio to individualize the academic programme and facilitate autonomous learning.

Education for advanced nursing practice: an evolving framework

This paper presents and critiques a framework for advanced health care practice. The framework is a set of professional attributes which underpin the delivery of an inter-disciplinary postgraduate course in the United Kingdom (UK). It enables students to review and develop knowledge and skills required to lead and advance nursing and health care practice. The framework is reviewed in relation to UK policy discussion on advanced or higher levels of practice. Brief comparisons are made with international concepts and literature on advanced nursing practice. The potential contribution of this framework to nursing practice and education is discussed. In particular, the framework provides a degree of clarity and coherence in specifying the nature and scope of advanced and higher level practice in the UK.

Nurse-sensitive outcomes of advanced practice

Advanced practice nurses (APNs) in the USA are registered nurses who hold masters or doctoral degrees in a specialized area of nursing. They provide advanced clinical care to clients, manage health care systems and influence health care decision-making through expert clinical reasoning and research and theory-based action. APN impact on health care outcomes is supported by studies using physician-focused indicators, although a few studies have identified several that are sensitive to or reflective of advanced practice nursing. A modified Delphi survey was conducted during May 1997-December 1998 to determine the outcome indicators APNs recommend for use in measuring their effect on care delivery outcomes. A convenience sample of 66 APNs attending a statewide outcomes conference identified 27 potential outcome indicators. These indicators were included in a mailed survey sent to APNs working in Tennessee. Respondents were asked to rate each indicator for validity, sensitivity, feasibility, utility and cost. In the second round of the survey, they were asked whether or not they agreed with the rank ordering of indicators, which was determined by the means calculated from responses in the first round. The 10 highest ranked indicators were satisfaction with care delivery, symptom resolution/reduction, perception of being well cared for, compliance/adherence with treatment plan, knowledge of patients and families, trust of care provider, collaboration among care providers, frequency and type of procedures ordered and quality of life. APNs identified both direct and indirect measures of effect on care delivery outcomes. Some of these are currently used as indicators of advanced practice, but many are not. Additional research is needed to determine whether the indicators proposed are valid and sensitive to advanced practice care by nurses.

Shaping advanced nursing practice in the new millennium

OBJECTIVES

To provide a review of converging themes and trends that are shaping advanced practice nursing roles in oncology nursing.

DATA SOURCES

Review and research articles, text-books, and organization documents.

CONCLUSIONS

The current managed care environment provides many opportunities and challenges for oncology advanced practice nurses. Advanced practice nurses have both clinical and organization competencies that enable them to mediate the clinical needs of patients and organization goals within the health care system.

IMPLICATIONS FOR NURSING PRACTICE

Advanced practice nurses can help shape their roles and practice by active participation in the development of systems to support access to clinical and financial information for effective decision making, collaboration among disciplines, and incorporating evidence-based care in their clinical practices.

Clinical practice of doctorally prepared nurses

This study describes the clinical experiences of doctorally prepared nurses whose primary professional role is providing care as advanced practice nurses. Telephone interviews were conducted with 20 participants who lived and practiced in 13 states. Practice settings for these nurses included inpatient acute care and various outpatient/community health settings. Several themes describe the nature of the participants' practice: management of patient care, interwoven partnerships, leadership, and practice values. Major themes relating to the contribution of doctoral education to practice were abilities gained and changes in image and status. The findings of this study demonstrate that doctorally prepared nurses are actively involved in nursing practice by affecting patient outcomes, promoting cost-effective care, and using clinical research.