The core of advanced practice nursing

Keeping the Nurse in the Nurse Practitioner: Returning to Our Disciplinary Roots of Knowing in Nursing

Nurse practitioners are a vital and growing body of primary healthcare providers. The ever-changing advancements in science and technology and the increasing complexities in health care delivery are significant factors culminating in the expanding role of nurse practitioner-led care. Nurse educators are striving to develop nurse practitioner curricula to keep pace with the increasingly sophisticated knowledge and competencies nurse practitioners must possess to render safe quality care as independent primary health care providers. However, nursing theory is losing its place as a formative foundation in nurse practitioner curricula. Multiple factors such as content-laden, competency-based, medically focused education have caused a diminishing presence of nursing theory, shrinking the philosophical basis for nursing in nurse practitioner education. The loss of the central unifying focus of the discipline and discipline-specific knowledge (nursology) risks losing the very identity that forms the basis and relevance for nurse practitioner practice. Moreover, the loss of the nurse in the nurse practitioner unmoors nurse practitioner practice from its theoretical and scientific basis, losing discipline-specific attributes that lead to higher levels of patient satisfaction and improved patient outcomes. Keeping the nurse in the nurse practitioner is a moral imperative in nurses' ethical and social contract with society. This article discusses relevant literature and offers recommendations to keep the nurse in the nurse practitioner.

The Impact of Worksite Clinics on Teacher Health Care Utilization and Cost, Self-Reported Health Status, and Student Academic Achievement Growth in a Public School District

OBJECTIVE

The aim of this study was to examine the impact of worksite clinics on health care utilization and cost, self-reported health status, and student achievement growth in a public school district.

METHODS

We used insurance claims, health risk assessment, and student achievement growth data for active teachers during 2007 to 2015. A difference-in-differences approach was applied to measure the impact of worksite clinics.

RESULTS

Compared with using a community-based clinic as the usual source of primary care, using a worksite clinic was associated with significantly lower inpatient admissions (53 vs 31 per 1000 teacher years), annual health care cost ($5043 vs $4298 in 2016 US dollars, a difference of $62 per teacher per month), and annual absent work hours (63 vs 61). No significant differences were detected in self-reported health status or student achievement growth.

CONCLUSION

Worksite clinics reduce teacher health care cost and absenteeism.

The Impact of Using Mid-level Providers in Face-to-Face Primary Care on Health Care Utilization

BACKGROUND

There has been concern that greater use of nurse practitioners (NP) and physician assistants (PA) in face-to-face primary care may increase utilization and spending.

OBJECTIVE

To evaluate a natural experiment within Kaiser Permanente in Georgia in the use of NP/PA in primary care.

STUDY DESIGN

From 2006 through early 2008 (the preperiod), each NP or PA was paired with a physician to manage a patient panel. In early 2008, NPs and PAs were removed from all face-to-face primary care. Using the 2006-2010 data, we applied a difference-in-differences analytic approach at the clinic level due to patient triage between a NP/PA and a physician. Clinics were classified into 3 different groups based on the percentage of visits by NP/PA during the preperiod: high (over 20% in-person primary care visits attended by NP/PAs), medium (5%-20%), and low (<5%) NP/PA model clinics.

MEASURES

Referrals to specialist physicians; emergency department visits and inpatient admissions; and advanced diagnostic imaging services.

RESULTS

Compared with the low NP/PA model, the high NP/PA model and the medium NP/PA model were associated with 4.9% and 5.1% fewer specialist referrals, respectively (P<0.05 for both estimates); the high NP/PA model and the medium NP/PA model also showed fewer hospitalizations and emergency department visits and fewer advanced diagnostic imaging services, but none of these was statistically significant.

CONCLUSIONS

We find no evidence to support concerns that under a physician's supervision, NPs and PAs increase utilization and spending.

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 critical engagement with the concept of advancing nursing practice

AIM

This paper aims to elucidate the concept of advancing nursing practice by engaging critically with developments in policy in the UK and ongoing debates in the international literature.

BACKGROUND

Advancing practice to the outer edges of nursing's scope of practice is a challenge for the profession both in the UK and elsewhere. However, defining what advancing nursing practice is and what it might become remains problematic.

EVALUATION

Critical analysis of published papers and policy documents pertaining to the concept of advancing nursing practice.

KEY ISSUE

Advancing nursing practice as a concept offers enormous potential for nurses and has been the subject of numerous debates over the last 25 years. Previous history of advanced practice offers no imperative practice and informs us little about the future roles of advanced nurse practitioners.

CONCLUSION

Current understanding about the role of advanced nurse practitioner and the nature of advanced practice remains unclear. Measuring the impact and outcome of the complex advanced practice nursing roles remains a challenge.

IMPLICATIONS FOR NURSING MANAGEMENT

While it is difficult to articulate succinctly what constitutes advancing nursing practice, defining the activities nurses engage in, the skills and competencies involved and the qualities and attributes required help reduce the ambiguities of the role.

Nurse practitioners - or advanced clinical nurses?

This article reviews a specific finding from a research project that examined the experiences of students, teachers and clinicians involved in a nurse practitioner degree programme. The development of advanced clinical nursing roles has presented challenges to the professional structure of nursing, particularly in the area of the unregulated and confusing array of titles adopted by nurses that infer advanced clinical practice. Over a 2-year period, practitioner ethnography was used to examine a sample of 10 student nurse practitioners who were undertaking a clinical degree programme (BSc (Hons) Nurse Practitioner). Data were also collected from 11 other individuals involved in the degree programme: teachers, medical mentors and senior academics. The data were systematically analysed and structured, leading to the inductive identification of themes and frameworks. The sample's experience of the development of advanced clinical nursing roles led to consideration of the evolution of new career structures and identities associated with advanced nursing practice. This evidence enabled a view of advanced clinical nursing roles within a framework of advanced nursing practice. The development of advanced clinical nursing is dependent on the cooperation of clinical nurses, educators, managers, doctors and politicians. Nevertheless, that development can only succeed if strategic policy is backed by the development of a professional clinical nursing career framework that enables the process.

Clinical expertise in advanced practice nursing: a Canadian perspective

The need to articulate clearly the definition and description of advanced nursing practice is critical if the nursing profession is to move forward in the development of nursing practice. Concern arises when the core of advanced practice nursing is overshadowed with medical functions. Consensus on the educational preparation of advanced practice nurses, explication of the nature of clinical expertise in advanced practice, and clarity of its nature are issues that the nursing profession must achieve greater precision in understanding and explaining. Advanced practice nurses must be able to practice in a milieu that will allow them to function to their full scope of practice.

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.

Consequences of not "knowing the patient"

"Knowing the patient" is an emerging concept in nursing that appears to be a central aspect of practice. "Knowing the patient" encompasses the complex process whereby the nurse acquires understanding of a specific patient as a unique individual, which subsequently enhances clinical decision-making, selection of optimal nursing interventions, and patient outcomes. Despite these heralded benefits, "knowing the patient" is severely undervalued in contemporary health care. Organizational arrangements, economic restraints, and efficiency of healthcare systems currently are of top priority. The potential effect on nursing practice is disconcerting; the effect on the discipline and the patient potentially devastating. This article explores the specific bureaucratic obstacles that impinge on "knowing the patient" within the context of nursing practice. It is hoped that illumination of the issues will beget viable alternative solutions, facilitating the transformation of awareness into action.

The Scope of Professional Practice: A literature review to determine the document's impact on nurses' role

Following the UKCC's publication of The Scope of Professional Practice (Scope) in 1992, it commissioned a study to investigate the document's impact. As part of the study, a review of the literature relating to Scope and its application was undertaken. Given the association of expanded practice using Scope, with new nursing roles and titles, the British and American literature relating to clinical nurse specialists and advanced practice was included in the review. This was undertaken because of the considerable influence from America on developments in this area in Britain.

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.

Influence of managed care on professional nursing practice

PURPOSE

To explore how nurses in one U.S. state perceived that managed care influenced professional nursing in that state. The nursing community is challenged to move with haste in demonstrating, through research, the clinical and economic value that nurses add to cost-effective outcomes.

DESIGN

A Delphi survey in 1996 of a convenience sample of 84 clinical nurse specialists (CNSs) and nurse practitioners (NPs) in California.

METHODS

CNSs and NPs contributed to the list of managed care influences on nursing practice. fifty-seven (68%) completed the third and final round.

FINDINGS

Panelist agreement was the highest for (a) exploring new approaches to providing quality care more cost-effectively, (b) expanding nurse practitioners' role in primary care, and (c) more effectively partnering with clients in helping them assume greater self-responsibility for their health. Greatest threats were perceived to be hassles involved in seeking authorization for care and responding to payment denials; the tenuous job market for nurses; and encroachment on nursing practice by others.

CONCLUSIONS

The findings can assist nurses in states with low managed-care concentration to create their preferred future within health care delivery. A more highly educated nurse workforce will be needed for 21st century health systems in which more care is likely to be delivered outside hospitals.

Identifying the practice characteristics of advanced practitioners in acute and critical care settings

This paper reports the results of a longitudinal, qualitative study into the role transition of advanced nurse practitioners (ANPs) in the UK. Following the completion of a Master's Degree in Health Studies programme, eleven ANPs working in high-dependency and acute care settings completed a purpose-designed 'role development diary' for the first six months they practised in their new role. In the diary, ANPs recorded the nature and focus of practice activities, identified the components of their practice perceived to be 'advanced', and documented the factors that influenced role implementation and development. Once completed, the diaries were subjected to a comparative analysis, which revealed that the level of patient dependency and the type of clinical environment had a direct bearing on the nature and extent of certain aspects of role performance. The findings also indicated that, whilst practitioners identified multiple components in their roles, priority was initially given to the acquisition and development of technical and diagnostic skills. It was concluded that variations in the performance of ANPs could be attributed not only to the nature of the clinical environment, but prevailing personal, political and organizational agendas.

The impact of change on the tissue viability nurse specialist: 1

Tissue viability nurse specialists in the UK have experienced difficulty in articulating their role, and this has led to a poor understanding of what they do. This article, the first of two parts, presents a literature review which examines the development of specialism in nursing and explores the factors that have influenced the development of tissue viability specialist nurses in the UK. The study described in the second part of the article uses focus group methodology to examine the practices and experiences of tissue viability nurses working in a changing healthcare environment.

A framework for advanced practice nursing

The empirical and expository literatures about advanced nursing practice have lacked a broad, comprehensive, conceptual framework to organize and guide substantive work. Such a framework is needed during the development of health care policy, educational curricula, role descriptions, and research agendas for this arena of practice. The framework proposed in this article represents an integrative synthesis of previous work on advanced nursing practice. The proposed framework is based on the definition of advanced practice nursing as professional health care activities that (1) focus on clinical services rendered at the nurse-client interface, (2) use a nursing orientation, (3) have a defined but dynamic and evolving scope, and (4) are based on competencies that are acquired through graduate nursing education. Advanced practice nursing is comprised of activities in the domains of advanced clinical practice, health care systems management, and professional involvement in broad health care discourse.

Sensoristrain: an exploration of nursing interventions in the context of the Neuman systems theory

Defining what nurses do and why has been the endeavour of many researchers, both academic and clinical. Nursing interventions are a fundamental component of nursing practice and a focus on accountability means that nurses must be able to justify their actions. The sensoristrain experience of intensive care patients is widely acknowledged in nursing literature, though without the use of the word 'sensoristrain'. The aim in this paper is to place patients, their experience and the role of nurses within the practical framework of a suitable nursing theory which will elucidate and guide everyday practice in preventing and alleviating the causes (stressors), symptoms (reactions) and emotional aftermatch. Nursing interventions appropriate for the three modalities of intervention elucidated by the Neuman systems theory have been outlined, paralleled by a discussion of how these could relate to the three dimensions of nursing care: comfort care; knowing the patient; and the therapeutic presence of the nurse. Nurses must use each opportunity to advance practice through emphasizing the value of nursing in today's cost-conscious health care climate. In order to do this, and to ensure nurses' continued presence at the bedside, clear articulation of the contribution of nursing interventions to improved patient outcomes is essential.

Palliative care: new challenges for advanced practice nursing

The terminally ill are emerging as a specialized patient population that needs the expanded skills and knowledge of advanced practice nurses. These nurses can follow patients across a variety of settings in an integrated system of health care and over the continuum of living and dying. This paper addresses the concept of palliative care and the advantages of advanced practice nurse leadership in this area. Four major criteria for the establishment of a new advanced practice nursing area (American Nurses Association, 1995) serve as a framework. These criteria are: the area lies within the scope of nursing practice; a documented need exists; there is a body of knowledge upon which to base the practice; and the field of nursing would be diminished if the need were ignored. The author maintains that there is sufficient evidence for the creation of a new role: advanced practice nurse in palliative care.