NSG 6006 Study Guide Policies & Practice Standards • State Nurse Practice Act

NSG 6006 Study Guide Policies & Practice Standards • State Nurse Practice Act NSG6006 Study Guide 5000 (Roles) • _History and Developmental 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 their education and training is in alignment with the recommendations of the Institute of Medicine (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 (). 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 ( 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 (). 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 ( • _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 specialization drew increasing numbers of physicians away from primary care, many areas of the country were designated underserved with respect to the numbers of primary care physicians. “Report after report issued by the AMA [American Medical Association] and the Association of American Medical Colleges decried the shortage of physicians in poor rural and urban areas” (Fairman, 2002, p. 163). At the same time, consumers across the nation were demanding accessible, affordable, and sensitive health care while health care delivery costs were increasing at an annual rate of 10% to 14% (Jonas, 1981). o Certified nurse midwife- 1955 Throughout the eighteenth and nineteenth centuries, lay midwives, rather than professional nurses or physicians, assisted women in childbirth. Midwives who were brought to the United States with the slave trade in 1619, and others who arrived later with waves of European immigration, were respected community members. In the late nineteenth and early twentieth centuries however, these untrained midwives would lose respect as scientific, hospital-based deliveries became the norm. Meanwhile, women in isolated communities throughout the country, particularly in rural settings, continued to employ lay midwives for deliveries well into the twentieth century. In the early twentieth century, national concern about high maternal-infant mortality rates led to heated debates surrounding issues of midwife licensing and control; lay midwives would soon be blamed for the high maternal and infant mortality rates that plagued the United States. In 1914, Dr. Frederick Taussig, speaking at the annual meeting of the National Organization of Public Health Nursing (NOPHN) in St. Louis, proposed that the creation of “nurse-midwives” might solve the “midwife question” and suggested that nurse-midwifery schools be established to train graduate nurses (Taussig, 1914). Later in the decade, the Children's Bureau called for efforts to instruct pregnant women in nutrition and recommended that public health nurses teach principles of hygiene and prenatal care to so-called granny midwives (Rooks, 1997) There are many different settings in which a CNM may practice. A CNM may engage in full-scope practice, which can include care of women from adolescence though the postmenopausal period. She or he may also choose one segment of practice—for example, ambulatory care or hospital care—or work exclusively with a population of interest, such as HIV-positive women or young adolescents. Nurse-midwives practice in urban, suburban, and rural areas. Their practice settings can include private practice (nurse-midwife—owned or physician-owned), hospitals, free-standing birth centers, clinics, or homes. Nurse-midwifery practice can be part of a group practice, with any combination of physicians, nurse-practitioners, physician assistants, or other health care providers, or solo practice. The nurse-midwife's actual practice depends on the needs of the population being served, willingness to undertake a variety of functions or roles, particular requests of patients, availability of physicians and nurse-midwife colleagues for backup and coverage and, finally, personal and philosophical beliefs of the individual midwife (Ament, 2007). A nurse-midwife—assisted birth can take place in homes, free-standing birth centers, birth centers in hospitals, or traditional hospital settings (community, regional, or tertiary). For nurse-midwives and the women for whom they provide care, the choice of setting may be a matter of philosophy, comfort, convenience, or degree of medical risk, or a combination of these factors. Each setting has unique advantages and disadvantages. Home births are very family-centered. Risks of iatrogenic and nosocomial infections are minimized. After the birth, the woman can rest or sleep in her own bed, nurse her infant at will, and enjoy the attention and support of her family and friends. A study by Hutton and coworkers (2009) documented the outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario Canada. The rate of perinatal and neonatal mortality was very low for both groups (0.1%), and no between-group differences in morbidity or mortality were noted. Access to emergency transfer is critical to safe care and good outcomes, as is an integrated maternity care system with excellent communication among providers (Home Birth Consensus Summit, 2011). Analgesia and regional anesthesia are not available in the home setting. The free-standing birth center has a homelike environment, with some select emergency equipment. Most birth centers do not use analgesics or narcotics. Local anesthesia may be used for perineal repair. Disadvantages are similar to those of a home birth in that emergency transport to a hospital may be necessary if the mother or baby develops complications during labor or birth. Most families are discharged within 6 to 12 hours of birth. Current U.S. hospital units for labor and birth tend to be dual-purpose rooms; women labor and give birth in the same room, and almost all rooms are private. The room has a rocking chair, pull-out couch, and private bath, with a tub or shower. Although individual and nicely appointed, these rooms are part of the larger medical environment, with fetal monitoring, operating rooms, anesthesia services, and immediate access to neonatal intensive care. The support people available (nurses, physicians) may not hold the same philosophy of birth as a midwife. Even for a low-risk woman, there is more of a tendency to intervene than support a normal physiologic birth. There is a production pressure to keep things moving and a reliance on technology that is palpable in a busy obstetric unit. The traditional hospital labor, delivery, and maternity units are designed to care for several women at a time, making the units easier for staff to function but not necessarily conducive to the normal labor process. These units are well suited for high-risk women and infants who need special care nurseries. However, midwife-attended births in the United States currently occur mostly in a hospital environment. Therefore, it is incumbent on the midwife to help create an atmosphere of normalcy and trust in the midst of a culture of technology. o Certified registered nurse anesthetist-1945 roots of nurse anesthesia in the United States can be traced to the late nineteenth century. During the 1860s, two key events converged—the widespread use of the newly discovered chloroform anesthesia and the demand for such treatment for wounded soldiers during the American Civil War (1861 to 1865). In 1861, except for Catholic sisters and Lutheran deaconesses, there were few professional nurses in the United States. There were only a handful of nurse training schools1 in the country and, for the most part, laywomen cared for families and friends when they were ill. When the first shots were fired on Fort Sumter and Civil War broke out, thousands of laywomen from the North and South volunteered to nurse. Because of social restrictions, these women actually did little hands-on nursing. Instead, they helped by reading to patients, serving them broths and stimulants such as tea, coffee, and alcohol, and assisting with the preparation of food in diet kitchens. Catholic sisters who nursed were given more freedom to provide direct care; their work included assisting in surgery, particularly with the administration of chloroform. Because the administration of chloroform was a relatively simple procedure in which the anesthetizer poured the drug over a cloth held over the patient's nose and mouth, the nuns quickly mastered this technique, providing the surgeons with invaluable assistance during the war (Jolly, 1927; Wall, 2005). At St. Mary's Hospital in Rochester, Minnesota, Dr. William Worrall Mayo was among the first physicians in the country to recognize and train nurse anesthetists formally. In 1889, Dr. W.W. Mayo hired Edith Granham to be his anesthetist and office nurse. Subsequently, he hired Alice Magaw (later referred to as the “mother of anesthesia”; Keeling, 2007) CRNAs provide services in conjunction with other health care professionals such as surgeons, dentists, podiatrists, and anesthesiologists in diverse clinical settings. These APNs practice in a variety of clinical environments. Nurse anesthetists provide anesthesia services on a solo basis, in groups, and collaboratively. Some CRNAs have independent contracting arrangements with physicians or hospitals. Today, most surgery is performed on a same-day admission or outpatient basis. Anesthesia practices have adapted to this change from a predominantly inpatient model for surgery. A number of mechanisms, ranging from preoperative telephone interviews to preanesthesia clinics, are used to conduct preanesthesia assessment and allow anesthesia providers an opportunity to discuss care options, procedures, and risks with patients. However, detailed physical assessment and establishing a rapport between the anesthesia provider and patient often still occurs on the day of surgery. • Essentials of masters and doctoral education for APNs – Initially, this initiative was aimed at ensuring adequate educational preparation for APNs and was developed in response to the reality of ever-increasing curricular requirements in master's programs throughout the country (Keeling, Kirschgessner & Brodie, 2010). As originally proposed by the AACN, the DNP would standardize practice entry requirements for all APNs by the year 2015, assuring the public that each APN would have had 1000 supervised clinical hours prior to entering the practice setting. (The DNP has also broadened to include nurses with specialties such as informatics, administration, and public health. See Chapter 3 for further discussion of DNP education for non-APNs.) Moreover, the proposed curriculum for DNPs would include competencies deemed essential for nursing practice in the twenty-first century, including the following: (1) scientific underpinnings for practice; (2) organizational and systems leadership; (3) clinical scholarship and analysis for evidence-based practice; (4) information systems technology; (5) health care policy; (6) interprofessional collaboration; and (7) clinical prevention and population health (AACN, 2006). Although it is too early to evaluate this initiative from a historical perspective, the national dialogue to move APN education to a practice doctorate offers significant opportunity for the profession to connect scientific evidence and practice (Magyary, Whitney, & Brown, 2006). Expanded educational preparation could position APNs to be vital players in the translation of research evidence at the point of care, help nursing education achieve parity with physician education, and potentially decrease interprofessional tensions. • Core competencies of practice- 1- excellence in direct clinical practice Although clinical expertise is a central ingredient of an APN's practice, the direct care practice of APNs is distinguished by six characteristics: (1) use of a holistic perspective; (2) formation of therapeutic partnerships with patients; (3) expert clinical performance; (4) use of reflective practice; (5) use of evidence as a guide to practice; and (6) use of diverse approaches to health and illness management 2-Guidance and coaching 3-Consultation 4-Evidence-based practice 5-Leadership 6-Collaboration 7-Ethical decision making • _ Fenton and Brykczynski’s Expert Practice Domains The seven domains are as follows (Benner, 1984): 1-the helping role, 2-administering and monitoring therapeutic interventions and regimens 3-effective management of rapidly changing situations 4-diagnostic and monitoring function 5-teaching and coaching function 6-monitoring and ensuring the quality of health care practices 7-organizational and work role competencies. • _Practice environments, regulation, reimbursement Later in the decade, with the new requirement that CRNAs have a master's degree, the number of nurse anesthesia education programs declined significantly, largely because of the closure of many small certification programs. However, the new requirement that programs offer a graduate degree did, in fact, promote nurse anesthesia eduction. In 1973, the University of Hawaii opened the first master's degree program for nurse anesthesia, moving the role forward in the evolving criteria of advanced practice nursing. Reimbursement for CRNA practice was not as clear-cut. In fact, third-party payment had its own set of issues. Beginning in 1977, the AANA led a long and complex effort to secure third-party reimbursement under Medicare so that CRNAs could bill for their services. The organization would finally succeed in 1989. Meanwhile, the financial threat posed by CRNAs to physicians was the source of continued interprofessional conflicts with medicine. During the second half of the twentieth century, tensions escalated, particularly in relation to malpractice policies, antitrust, and restraint of trade issues. In 1986, Oltz v. St. Peter's Community Hospital established the right of CRNAs to sue for anticompetitive damages when anesthesiologists conspired to restrict practice privileges. A second case, Bhan v. NME Hospitals, Inc. (1985), established the right of CRNAs to be awarded damages when exclusive contracts were made between hospitals and physician anesthesiologists. Undeniably, CRNAs were winning the legal battles and overcoming practice barriers erected by hospital administrators and physicians. The creation of the National Association of Clinical Nurse Specialists (NACNS), followed by third-party reimbursement for their services, represented two major steps for the CNS. NACNS was formed In 1995, promoting organization of the role at the national level. Soon thereafter, in 1997, the Balanced Budget Act (Public Law 105-33) specifically identified the CNS as eligible for Medicare reimbursement (Safriet, 1998). The law, providing Medicare Part B direct payment to NPs and CNSs, regardless of their geographic area of practice, allowed both types of APNs to be paid 85% of the fee paid to physicians for the same services. Moreover, the law's inclusion and definition of CNSs corrected the previous omission of this group for reimbursement (Safriet, 1998). The possibility of reimbursement for services was an important step in the continuing development of the CNS role because hospital administrators would continue to focus on the cost of having APNs provide patient care. Some CNS roles require prescription of medications and the ability of a CNS to prescribe depends on state regulations. As of January 2012, CNSs have independent prescriptive authority in 11 states and in Washington, DC, no prescribing authority in 15 states, and nonindependent prescriptive authority in the remaining 24 states (National Council of State Boards of Nursing, 2012). NPs worked_ outpatient clinics, health maintenance organizations, health departments, community health centers, rural clinics, schools, occupational health clinics, and private offices • _Dreyfus & Dreyfus: Development of the APN role-novice to expert theory (add theories and models) Acquisition of knowledge and skill occurs in a progressive movement through the stages of performance from novice to expert, as described by Dreyfus and Dreyfus (1986, 2009), who studied diverse groups, including pilots, chess players, and adult learners of second languages. The skill acquisition model has broad applicability and can be used to understand many different skills better, ranging from playing a musical instrument to writing a research grant. The most widely known application of this model is Benner's (1984) observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors in hospital nursing services. Although this study included several APNs, it did not specify a particular education level as a criterion for expertise. As noted in Chapter 3, there has been some confusion about this criterion. The skill acquisition model is a situation-based model, not a trait model. Therefore, the level of expertise is not an individual characteristic of a particular nurse but is a function of the nurse's familiarity with a particular situation in combination with his or her educational background. This model could be used to study the level of expertise required for other aspects of advanced practice, including guidance and coaching, consultation, collaboration, evidence-based practice ethical decision making, and leadership (see Brykczynski [2009] for a detailed discussion of the Dreyfus model). The overall trajectory expected during APN role development is shown in Figure 4-1; however, each APN experiences a unique pattern of role transitions and life transitions concurrently. For example, a professional nurse who functions as a mentor for new graduates may decide to pursue an advanced degree as an APN. As an APN graduate student, she or he will experience the challenges of acquiring a new role, the anxiety associated with learning new skills and practices, and the dependency of being a novice. At the same time, if this nurse continues to work as a registered nurse, his or her functioning in this work role will be at the competent, proficient, or expert level, depending on experience and the situation. On graduation, the new APN may experience a limbo period, during which the nurse is no longer a student and not yet an APN, while searching for a position and meeting certification requirements (see later). Once in a new APN position, this nurse may experience a return to the advanced beginner stage as he or she proceeds through the phases of role implementation. Even after making the transition to an APN role, progression in role implementation is not a linear process. As Figure 4-1 indicates, there are discontinuities, with movement back and forth as the trajectory begins again. Years later, the APN may decide to pursue yet another APN role. The processes of role acquisition, role implementation, and novice to expert skill development will again be experienced—although altered and informed by previous experiences—as the postgraduate student acquires additional skills and knowledge. Role development involves multiple, dynamic, and situational processes, with each new undertaking being characterized by passage through earlier transitional phases and with some movement back and forth, horizontally or vertically, as different career options are pursued. Direct-entry students who are non-nurse college graduates (NNCGs) and APN students with little or no experience as nurses before entry into an APN graduate program would be expected to begin their APN role development at the novice level (see Fig. 4-1). Some evidence indicates that although these inexperienced nurse students may lack the intuitive sense that comes with clinical experience, they avoid the role confusion associated with letting go of the traditional RN role commonly reported with experienced nurse students (Heitz, Steiner, & Burman, 2004). This finding has implications for APN education as the profession moves toward the Doctor of Nursing Practice (DNP) as the preferred educational pathway for APN preparation (American Association of Colleges of Nursing [AACN], 2006). Another significant implication of the Dreyfus model (Dreyfus & Dreyfus, 1986, 2009) for APNs is the observation that the quality of performance may deteriorate when performers are subjected to intense scrutiny, whether their own or that of someone else (Roberts, Tabloski, & Bova, 1997). Novice and Advanced Practice Nurses Participate in professional organizations and become involved in regulatory activities, such as educating lawmakers, providing public comment on APRN issues, writing letters, and being part of campaign activities: •Monitor current APRN legislation and legislation that affects patients. •Offer to participate in test-writing committees for national certification examinations as item writers and/or reviewers. •Respond to offers to review, edit, and provide feedback about circulated draft regulatory policies that directly affect advanced practice nursing education and practice. Experienced and Expert Advanced Practice Nurses • Seek out a gubernatorial appointment to the board of nursing or advanced practice committee that advises the board of nursing in your state. • Seek membership as the APRN or consumer member of the advisory council for the state medical board or state board of pharmacy. • Seek appointment to CMS panels on which Medicare and Medicaid provider issues are decided. • Seek appointment to hospital privileging committees and ensure that privileging materials are appropriate for APRNs. • Seek appointment on advisory committees and task forces that are advising the NCSBN and other regulatory and credentialing bodies. • Provide public comment on draft legislation regarding health care and health care providers. • Offer testimony at state and national hearings at which proposed regulatory changes in advanced practice nursing regulation, prescriptive authority, and reimbursement schemes will be discussed. To accomplish these activities, APRNs need to use research data, a powerful tool for shaping health policy (Hamric, 1998). By actively participating in the regulatory process, APRNs ensure themselves of a strong voice in regulatory and credentialing processes. At the very least, it is incumbent on the practicing APRN to monitor the process carefully through websites and newsletters to stay informed. • _Novice to Expert Skill Acquisition Model • _Role Concepts; Concept Definition Examples 1-Role stress- A situation of increased role performance demand Ex. Returning to school while maintaining work and family responsibilities 2-Role strain- Subjective feeling of frustration, tension, or anxiety in response to role stress Ex. Feeling of decreased self-esteem when performance is below expectations of self or significant others 3-Role stressors- Factors that produce role stress Financial, personal, or academic demands and role expectations that are ambiguous, conflicting, excessive, or unpredictable 4-Role ambiguity- Unclear expectations, diffuse responsibilities, uncertainty about subroles Ex. Some degree of ambiguity in all professional positions because of the evolving nature of roles and expansion of skills and knowledge 5-Role incongruity- A role with incompatibility between skills and abilities and role obligations or between personal values, self-concept, and role obligations Ex. An adult NP in a role requiring pediatric skills and knowledge 7-Role transition -A dynamic process of change over time as new roles are acquired Ex. Changing from a staff nurse role to an APN role 8-Role insufficiency- Feeling inadequate to meet role demands Ex. New APN graduate experiencing the imposter phenomenon (Arena & Page, 1992; Brown & Olshansky, 1998) 9-Role supplementation- Anticipatory socialization Ex. Role-specific educational components in a graduate program 10-Role Implementaion- an example of a situational transition (Schumacher & Meleis, 1994), which has been described as a progressive movement through phases. There is general agreement that significant overlap and fluidity exist among the phases. However, for purposes of discussion, the phases will be considered sequentially. 6-Role conflict- Occurs when role expectations are perceived to be mutually exclusive or contradictory Ex. Role conflict between APNs and other nurses and between APNs and physicians The historical development of APN roles has been fraught with conflict and controversy in nursing education and nursing organizations, particularly for CNMs (Varney, 1987), NPs (Ford, 1982), and CRNAs (Gunn, 1991; see also Chapter 1). Relationships among these APN groups and nursing as a discipline have improved markedly in recent years, but difficulties remain (Fawcett, Newman, & McAllister, 2004). The degree to which APN roles demonstrate a holistic nursing orientation as opposed to a more disease-specific medical orientation remains problematic (see value-added discussion under collaboration, later). Communication difficulties that underlie intraprofessional role conflict occur in four major areas: (1) at an organizational level; (2) in educational programs; (3) in the literature; and (4) in direct clinical practice. Kimbro (1978) initially described these communication difficulties in reference to CNMs, but they are relevant for all APN roles. The fact that CNSs, NPs, CNMs, and CRNAs each have specific organizations with different certification requirements, competencies, and curricula creates boundaries and sets up the need for formal lines of communication. Communication gaps occur in education when courses and textbooks are not shared among APN programs, even when more than one specialty is offered in the same school. Specialty-specific journals are another formal communication barrier because APNs may read primarily within their own specialty and not keep abreast of larger APN issues. In clinical settings, some APNs may be more concerned with providing direct clinical care to individual patients, whereas staff nurses and other APNs may be more concerned with 24-hour coverage and smooth functioning of the unit or institution. These differences may set the stage for intraprofessional role conflict. During the 1980s and 1990s, when there was more confusion about the delineation of roles and responsibilities between RNs and NPs, RNs would sometimes demonstrate resistance to NPs by refusing to take vital signs, obtain blood samples, or perform other support functions for patients of NPs (Brykczynski, 1985; Hupcey, 1993; Lurie, 1981), and they were not admonished by their supervisors for these negative behaviors. These behaviors are suggestive of horizontal violence (a form of hostility), which may be more common during nursing shortages (Thomas, 2003). Roberts (1983) first described horizontal violence among nurses as oppressed group behavior wherein nurses who were doubly oppressed as women and as nurses demonstrated hostility toward their own less powerful group, instead of toward the more powerful oppressors. Recognizing that intraprofessional conflict among nurses is similar to oppressed group behavior can be useful in the development of strategies to overcome these difficulties (Bartholomew, 2006; Brykczynski, 1997; Farrell, 2001; Freshwater, 2000; Roberts, 1996; Rounds, 1997; see Chapter 11). According to Rounds (1997), horizontal violence is less common among NPs as a group than among RNs generally. Over the years, as the NP role has become more accepted by nurses, there appear to be fewer cases of these hostile passive-aggressive behaviors, often currently referred to as bullying, toward NPs. However, they are still reported in APN transition literature (Heitz et al., 2004; Kelly & Mathews, 2001). • _Conceptual models for APNs a conceptual model designed to facilitate the evaluation of the acute care nurse practitioner (ACNP) role in acute care settings (Fig. 23-2). Developed in Canada, this model was adapted from a nursing role effectiveness model and is also a derivative of Donabedian's framework, with components focusing on structure (patient, ACNP, and organization), process (ACNP role components, role enactment, and role functions) and outcome (goals and expectations of the ACNP role). A concern with this model is the use of the term goals and expectations for outcome and the focus on quality of care, which is a dimension of care delivery process rather than outcome. Four processes (mechanisms) within the ACNP direct care component are expected to achieve patient and cost outcomes: (1) providing comprehensive care; (2) ensuring continuity of care; (3) coordinating services; and (4) providing care in a timely way (Sidani & Irvine, 1999). According to this model, the selection of outcome indicators is guided by the role and functions assumed by the ACNP, how the role is enacted, and the ACNP's particular practice model. Like the models before it, the usefulness of this framework for determining APN impact is limited by its virtual absence of testing in clinical settings. • _Conceptualization barriers Conceptualizations of the Nature of Advanced Practice Nursing The APN role-specific models promulgated by professional organizations naturally lead to the following questions: •What is common across APN roles? •Can an overarching conceptualization of advanced practice nursing be articulated? •How can one distinguish among basic, expert, and advanced levels of nursing practice? Some authors have attempted to discern the nature of advanced practice nursing and address these questions. The extent to which they considered all existing APN roles is not always clear; some authors have considered only the CNS and NP roles. In this section, the focus is on those frameworks that address the nature of advanced practice nursing. The term role is used loosely and variably, sometimes seeming to describe functions (e.g., management, teaching, research, consultation) and sometimes taking a psychological or sociologic perspective on developing social roles in relation to environment. Dictionary definitions add to the confusion by using the terms role, function, occupation, and duties to define one another. For example, role is generally used to refer to titles appearing in legal documents, certification programs, or job descriptions. From this perspective, the CNS, NP, CNM, and CRNA designations represent advanced practice roles. From the present review of a number of frameworks, domain and competency may be the most commonly used concepts in explaining nursing practice and advanced practice nursing. However, meanings are not consistent. Hamric's Model, which uses the terms roles and competencies, is the only one that is integrative—that is, it explicitly considers all four APN roles. Because it is integrative, has remained relatively stable since 1996, has informed the development of the DNP Essentials and CNS competencies, and is widely cited, it will be discussed first, enabling the reader to consider the extent to which important concepts are addressed by other models. Otherwise, the models are discussed in chronologic order. In most cases, new literature on the models discussed here were not found in literature searches in the Cumulative Index to Nursing and Allied Health Literature • _Hamric’s Integrative Model an integrative understanding of the core of advanced practice nursing, based on literature from all APN specialties (Hamric, 1996, 2000, 2005, 2009; see Chapter 3). Hamric proposed a conceptual definition of advanced practice nursing and defining characteristics that included primary criteria (graduate education, certification in the specialty, and a focus on clinical practice with patients) and a set of core competencies (direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, and leadership). This early model was further refined, together with Hanson and Spross in 2000 and 2005, based on dialogue among the editors. Key components of the model (Fig. 2-4) include the primary criteria for advanced nursing practice, seven advanced practice competencies with direct care as the core competency on which the other competencies depend, and environmental and contextual factors that must be managed for advanced practice nursing to flourish. • _Calkin’s Model of Advanced Practice Nursing The model evolved from the delineation of the domains and competencies of the acute care NP (ACNP) role, conceptualized as a role that “combines the clinical skills of the NP with the systems acumen, educational commitment, and leadership ability of the CNS” (Ackerman et al., 1996, p. 69). The five domains are direct comprehensive patient care, support of systems, education, research, and publication and professional leadership. All domains have direct and indirect activities associated with them. In addition, necessary unifying threads influence each domain, which are illustrated as circular and continuous threads in the figure • _Brown’sFramework for Advanced Practice Nursing developed a conceptual framework for the entire field of advanced practice nursing, including the environments that surround and impact upon practice (Fig. 2-7). Studies were synthesized to propose a conceptual framework that included 4 main and 17 specific concepts (specific concepts are in parentheses): environments (society, health care economy, local conditions, nursing, advanced practice community); role legitimacy (graduate education, certification, licensure); advanced practice nursing (scope, clinical care, competencies, managing health care environments, professional involvement in health care discourse); and outcomes (patient, health care system, the nursing profession, individual APN outcomes). The central concept, conceptually and visually, is advanced practice nursing. Brown (1998) proposed a definition of advanced practice nursing: “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.” • _Oberle and Allen At the time that they wrote, Oberle and Allen (2001) asserted that conceptualizations of advanced practice nursing were limited; particular gaps were the lack of clear distinctions between the expert practice of experienced nurses and of APNs, as well as the lack of nursing theories to address such levels of practice. The authors noted that, although the literature on expert nursing is mostly focused on expertise as it unfolds in the context of relationships, the literature on advanced practice nursing seems to focus more on expertise as “skills acquisition and critical thinking abilities.” According to Oberle and Allen (2001), any conceptualization of advanced practice nursing should be embedded in a conceptual understanding of nursing, so the authors first proposed a conceptualization of nursing practice. They refer to practice by the term praxis, which captures the values-oriented, reflective, and creative nature of the work of nurses. They conceive of nursing as a dialectic (back and forth) process between the nurse's knowledge and his or her experiences and relationships with patients. In this process, the nurse considers general and particular knowledge, synthesizes this knowledge, and generates options for care that can be offered to the patient. By this, they mean that experiences with patients (and, presumably, reflection on these experiences) extend nurses' knowledge, this new knowledge informs their practice with subsequent patients, and experiences with applying the new knowledge gained from experience and reflection again inform and extend their thinking, a dialectic process that occurs repeatedly. As nurses accumulate experience, this dialectic process that occurs in relationships with patients contributes to developing expertise. Client's meanings, desired outcomes, and acceptable actions—know who. • Dialectic—the process whereby nurses consider general and particular knowledge and synthesize this information to generate options and propose actions to the patient to move the patient toward his or her goals. • Synthesis—know that (a particular action is called for in a specific situation). • Practical wisdom—know when (a particular action ought to be taken). The dialectic process and experience with synthesis, informed by praxis, lead to the development of practical wisdom. • Telos—human flourishing (the object of nursing care, of which health is a part—health is a resource for human flourishing. • Options—possibilities for actions identified by nurse. • _Shuler Model of Nurse Practitioner Practice This model is complex and the review for this edition found no additional reports using this model. Because of its historical importance as an early NP model, the Shuler model (Shuler & Davis, 1993a) is briefly discussed. Readers should refer to the original article to see the full model. Shuler's experience integrating nursing and medical knowledge skills into the NP role led to the development of a conceptual model that would make apparent the unique contributions of NPs, purposefully addressing the need for a model that reflects the acquisition of expertise by the NP in two health care disciplines, nursing and medicine. Shuler's Nurse Practitioner Practice Model is a complex systems model that is holistic and wellness-oriented. It is definitive and detailed in terms of how the NP-patient interaction, patient assessment, intervention, and evaluation should occur (Shuler & Davis, 1993a). It is complex and its value for understanding NP practice may not become clear until one is in practice. Table 2-2 outlines key model constructs and related theories, many of which should be familiar to students. Knowing that these familiar concepts are embedded in this comprehensive model may help readers appreciate its potential usefulness. Shuler's model is intended “to impact the NP domain at four levels: theoretical, clinical, educational, and research” (Shuler & Davis, 1993a). A close review of the model indicates that it addresses important components of a model of advanced practice nursing, such as the following: (1) nursing's metaparadigm (person, health, nursing, and environment); (2) the nursing process; (3) assumptions about patients and nurse practitioners; and (4) theoretical concepts relevant to practice. The model could be characterized as a network or system of frameworks. • _Ball and Cox Theory they