Several APRN nursing models have reviewed and researched roles for this growing profession. Hamric’s integrative model of advanced nursing
practice is a very comprehensive model that includes primary criteria for the APRN as well as central and core competencies (Hamric, Spross, &
Hanson, 2013 ). Primary criteria included in this model are graduate ed- ucation, certification in the specialty, and a focus on clinical practice.
Core competencies referenced by Hamric , Spross, and Hanson (2013) are direct clinical practice, collaboration, guidance and coaching, evidence- based practice, ethical decision making, consultation, and leadership.
This model also incorporates outside elements affecting APRN practice.
A framework for advanced practice nursing developed by Brown ( 1998 , 2005) looked at the external issues, roles, APRN scope, and competencies, as well as outcomes of the APRN role. The Strong Model of Advanced Practice (Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996 ) is one of the few that has been tested for validity (Mick & Ackerman, 2000 ).
This model has also been supported throughout the literature and used in other research, such as the development of a role- delineation tool by Chang, Gardner, Duffied, and Ramis (2012).
The Strong Model breaks down APRN roles by service parameters.
These parameters include direct comprehensive care, support of systems, education, research, and publication and professional leadership. This model, with some modification, is used to further define APRN roles in this chapter.
Direct Care
Patient care is, and should remain, the priority of the APRN. Within this realm, several roles emerge, including patient advocate, educator to the pa- tient and family, case manager, and collaborator. All these roles rely on APRNs using evidence- based practice as a basis for their care and decision- making processes. APRNs need to be staunch supporters of continued research and integrate these findings into practice. The continued advance- ment of healthcare depends on a culture of support for new and innovative ideas (Ackerman et al., 1996 ).
Patient Advocate
Advocacy for patients must remain fundamental to the practice of nursing.
It is the underpinning of the nurse– patient relationship. "Advocacy” is de- fined as “the act, or process of pleading for, supporting, or recommending a cause or course of action” (Fowler, 2015 , p. 37). Advocacy has progressed to being a guardian of the patient’s rights and freedoms of choice. Although several other elements may be included in advocacy, a nurse’s advocacy is guided by respect for the individual (Fowler, 2015).
Advocacy can be viewed from a variety of perspectives. Nelson ( 1998 ) maintains that advocacy includes legal advocacy, moral– ethical advocacy, substitutive advocacy, political advocacy, and spiritual advocacy. Newer models of patient advocacy are focused on empowering patients to take an active role in their own healthcare, while still maintaining the role of evidence- based healthcare provider. In this sense, the APRN can educate
the patient on current practices, yet take a patient- centered approach in assisting the patient with his or her health.
In legal advocacy, the nurse supports the patient’s legal rights, such as in- formed consent or the right to refuse treatment. This may include ensuring that all patients have a copy of the institution’s bill of rights. Moral– ethical advocacy requires that the nurse respects the patient’s values and supports decisions that are consistent with those values, such as decisions regarding abortion. In substitutive advocacy, if the patient is unable to express an opinion, the nurse should continue to respect the rights of the patient or surrogate and support any wishes that the patient may have previously expressed. In spiritual advocacy, the APRN ensures that the patient has access to spiritual support such as clergy and that the plan of care includes the spiritual aspects of care.
Advocacy must occur for all patients. APRNs should advocate for all patients to complete living wills and advance directives to make sure that healthcare issues are well documented and patient wishes are respected. On occasion, issues of patient competency may arise in areas such as substitutive advocacy and moral– ethical advocacy. When com- petency is a concern, the APRN must be familiar with laws governing competence, including criteria for the assessment of competence. At the same time, the APRN should be instrumental in establishing policies for direct action when a patient is judged incompetent. In such a case, the APRN must communicate the patient’s expectations, if they are known, to the surrogate and/or the patient’s family to support any requests and decisions to be made based on the patient’s past recommendations.
Because there can be confusion and conflict among family, friends, surrogates, and even healthcare professionals during these times, the APRN should have no reservation about convening family– patient con- ferences and implementing ethics committee evaluations if questions or controversies arise.
Advocacy carries a significant ethical dimension; therefore, principles of ethics can help to evaluate a nurse’s effectiveness (ANA, 2015). Pinch ( 1996 ) points out that some ethical principles may conflict. For example, the principle of autonomy (self- determination) could clash with distribu- tive justice (fair, equitable distribution of goods or services) if the patient’s decisions were to affect the community’s greater need or safety. If a patient requested no treatment and is discharged with a dangerous communicable disease that may infect the community, or if a patient demanded resources that jeopardized the financial or medical resources of a community, the patient’s autonomy may be at risk of being overshadowed by what is best for the majority. In maintaining advocacy, the APRN would need to be sure that there was, indeed, a conflict in distributive justice and no prejudices existed toward an individual or group.
Concerns, in the past, have existed regarding the ability of a nurse to be an advocate, given our current healthcare systems and associated cost- containment measures (Donagrandi & Eddy, 2000 ; Kalaitzidis & Jewell, 2015; Nelson, 1998 ). Is the APRN in a position to maintain advocacy despite
the demands of the system? Nelson ( 1998 ) contends that the APRN can rise above these constraints. Cost- effectiveness is a strong suit of APRN practice. Payments for Medicare beneficiaries seeing an NP were ap- proximately 29% less than the payments for beneficiaries seeing an MD (Perloff, DesRoches, & Buerhaus, 2016 ). Multiple other studies have also demonstrated cost savings (Chenoweth, Martin, Pankowski, & Raymond, 2005 ; Eibner, Hussey, Ridgely, & McGlynn, 2009). On the individual pa- tient level, it has been well established that APRNs provide high- quality care, even in comparison with other provider types (Everett et al., 2013 ; Kuo, Chen, Baillargeon, Raji, & Goodwin, 2015 ; Kuo, Goodwin, et al., 2015 ).
The APRN is in a unique position of influence through interaction with other team members, ensuring advocacy through policy formulation that directs patient care and through legislative involvement. Additionally, the APRN should be well versed in the areas of evidence- based practice, standards of care, ethics policies, accreditation criteria, nursing licensure regulations, and professional association standards that can help support an APRN’s advocacy position.
Educator to the Patient and Family
Advanced practice nursing education makes the APRN an excellent re- source for current knowledge in content areas, supportive resources, re- search findings, and the implementation of evidence- based practice. This is imperative when educating patients and their families. Today’s health- care consumers are very knowledgeable about their health and medical treatment. Assessment of this knowledge base is essential. Patients are using the Internet as a primary source of information. Some sources have information that is directed to healthcare professionals and is more likely to be reliable. The information that individuals gather is generated from a wide variety of Internet sources, such as chat rooms, blogs, nonevidence- based medical sites, or sites with medical opinions from nonmedical personnel. Information also comes from advertisements, brochures, newspapers, television, health kiosks, nontraditional care providers, and family and friends. This information can be skewed, inaccurate, or incom- plete. The APRN should take the time to access and review these sources to appraise the accuracy and reliability of the information that is being provided. Patients may experience fears or preconceived ideas regarding care strategies and inappropriate outcomes. These apprehensions can ei- ther motivate them to become very knowledgeable or to remain very un- informed about their health concerns. Just as you might ask students for content references, the APRN should ask patients for their information sources.
The APRN needs to make a point of screening- related health informa- tion made available by the healthcare organizations as well. Many patients are overwhelmed simply by their diagnosis, much less their medication, treatment course, or plan of care. Therefore, most printed or electroni- cally distributed educational content should be constructed at a fifth- to
eighth- grade reading level. Background, color, and print format are other considerations. Printed or electronic information can be given to a patient to reinforce verbal information, but must be at the patient consumer level, not the medical professional level.
Case Manager
Case management is becoming a more common dimension of the APRN role with the enactment of the ACA. This role is greatly expanding with the implementation of more fixed or bundled reimbursement and in- clusion of more patients with preexisting conditions. Healthcare organ- izations are looking to APRN case managers to coordinate the care of these individuals to reduce costs while providing comprehensive care.
Coffman ( 2001 ) describes "case management" as a collaborative process promoting quality care and cost- effective outcomes to specific patients and groups. Umbrell ( 2006 ) outlines the value of an advanced practice trauma case manager in orchestrating a comprehensive plan to reduce fragmentation of care and better utilization of resources. The key features of the case manager as outlined by Benoit ( 1996 ) include (a) standard- ized resources for a length of stay for selected patient care, caregiver, and system outcomes; (b) collaborative team practice among disciplines;
(c) coordinated care over the course of an illness; (d) job enrichment for the caregiver; (e) patient and physician satisfaction with the care; and (f) minimized costs to the institution.
Taylor ( 1999 ) initially described the two primary types of case man- agement as (a) the patient- focused model, which supports the patient throughout the continuum of care and helps the patient access health- care, and (b) the system- focused model, which involves the service en- vironment and is structured for cost containment of a specific group of patients and use of critical pathways for cost- effective outcomes. However, Taylor advanced her model of comprehensive case management that incorporates elements of cultural competency, consumer empowerment, clinical framework, and multidisciplinary practice in addition to other activities of assessment, service, planning, plan implementation, coordi- nation and monitoring, advocacy, and termination. The focus in health- care is on patient empowerment and quality service based on process improvement, outcome measurements, and performance- based expec- tations. In the past, case management was associated with the utiliza- tion of clinical pathways to drive the plan of care— therefore focusing on process— but the focus since the early 2000s has been on outcome meas- ures. Taylor asserts that this new model is optimal because it incorporates components of both patient and system models to ensure that the patient receives needed services.
Ethical concerns have persisted as to how APRNs who are active in nursing and case management can remain advocates for patients in the new Accountable Care Organizations (ACO) and patient- centered med- ical home models. The disconnect is maintaining the five principles of
ethical behavior while attempting to follow insurance, reimbursement, and other regulations that will come up as a result of this new legisla- tion. The five principles include autonomy, beneficence, nonmaleficence, justice, and fidelity. These are basic principles we, as nurses, learn from the very beginning and need to bring forth despite other overreaching pressures.
The utilization of APRNs as case managers has been advocated (Donagrandi & Eddy, 2000 ; Taylor, 1999 ). APRNs have enhanced capabil- ities in interdisciplinary coordination, advanced clinical decision making, autonomy, synthesis, and critical thinking. The APRN expertise would also be valuable in the development of outcome standards, communication and coordination among disciplines, and analysis of patient care trends. In ad- dition, a focus on complex patient populations requiring extended lengths of stay or long- term care resources is very ably managed by the APRN (Abdellah, Fawcett, Kane, Dick, & Chen, 2005 ).
Collaborator
Collaboration integrates the individual perspectives and expertise of var- ious team members on behalf of providing quality patient care (Resnick
& Bonner, 2003 ). Interdisciplinary collaboration has become a hot topic in today’s healthcare environment. With escalating demands and the pro- spect of a rise in chronic illness, a cooperative effort among healthcare dis- ciplines will be the most effective means to provide quality care.
One of the key messages in the IOM’s report The Future of Nursing: Leading Change, Advancing Health (2011) is, “Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States” (p. 4). The ACA also emphasizes interdisciplinary col- laboration as a means to provide cost- effective and comprehensive care.
Matthews and Brown ( 2013 ) outline a collaborative health management model for effectively managing patients with chronic disease. This model includes the APRN, physician, registered nurse, medical assistant, pharma- cist, social worker, mental health provider, and specialty consultants. The authors focus on goals of promoting patient self- management, preventive or proactive care, and close follow- up (Matthews & Brown, 2013 ).
Unfortunately, there are varied thoughts about the definition of this collaborative process. Influences on these discrepancies include provider gender, level of professionalism, environment, and the traditional push for autonomy in the nursing field. Fast- paced clinical environments and tradi- tional hierarchical roles contribute to poor communication across the dis- ciplines. APRNs will need to lead the way to introduce the collaborative process as a professional behavior and best practice for the care of patients.
Systems Support
Within the paradigm of the healthcare system, the APRN needs to be a leader, a mentor, and a nursing advocate. These three roles ultimately
support optimal and innovative patient care practices. The roles are so intertwined that it is difficult to dissect one from the others. This section presents the three as a cumulative role of leader.
The U.S. Army defines "leadership” as “the process of influencing people by providing purpose, direction, and motivation to accomplish the mis- sion and improve the organization” (Army Doctrine Publication, 2012, p. 1).
There are many levels of both formal and informal leaders within the mil- itary structure. Some of these are by virtue of the position alone, which does not always constitute a good leader. Others, although not necessarily in a leadership position, clearly match the definition of a leader. An effec- tive leader earns respect by setting the example, promoting an open and caring environment, being an inspiration to others, using resources wisely, and creating a strong and supportive team. The role of a leader is relatively new and extremely important for the APRN. With the transition to DNP- prepared APRNs, the career field is now fully equipped to be the “tip of the spear” for change in our healthcare system.
The DNP- prepared APRN, although not a role in itself, contributes significantly to the advancement of APRNs in the leadership role. The AACN DNP essentials specify two key components geared toward lead- ership. The first is “Organizational and Systems Leadership for Quality Improvement and Systems Thinking.” The key here is emphasizing prac- tice while working to improve health outcomes and patient safety on a practice- level or system- wide basis. The second essential relating to lead- ership is “Health Care Policy for Advocacy in Health Care.” The DNP- prepared APRN has the capabilities to broaden the scope of nursing leadership and take on public and nursing profession policy issues (Ehrenreich, 2002 ).
The National Organization of Nurse Practitioner Faculties (NONPF) outlines NP leadership with seven core competencies: (a) assumes complex and advanced leadership roles to initiate and guide change;
(b) provides leadership to foster collaboration with multiple stakeholders to improve healthcare; (c) demonstrates leadership that uses critical and reflective thinking; (d) advocates for improved access, quality, and cost- effective healthcare; (e) advances practice through the development and implementation of innovations incorporating principles of change;
(f) communicates practice knowledge effectively, both orally and in writing; (g) participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a popula- tion focus (NONPF, 2017). The other APRN disciplines have similar com- petency statements. The CNS Systems Leadership Competency has 13 issues addressed within the leadership scope, including system change, fiscal and budgetary decision making, evaluation of the effect of nursing, dissemination of outcomes of change, provision of clinically competent care by team, assessments performed at the systems level, and interdisci- plinary collaboration (National Association of Clinical Nurse Specialists [NACNS], 2010). The American Association of Nurse Anesthetists (AANA,
2013 , p. 1) states, “Nurse anesthetists are innovative leaders in anesthesia care delivery, integrating progressive critical thinking and ethical judg- ment.” The American College of Nurse- Midwives (ACNM) delineates leadership competencies as professional responsibilities of the CNM.
Some of the outlined responsibilities include knowledge of national and international issues and trends, support of legislation and policy initiatives, and knowledge of issues and trends in healthcare policy and systems (ACNM, 2012 ).
There are obviously varied levels of leadership. The APRN is well suited for this role at all levels, including clinical, system, community, national, and international. Clinically, the APRN is automatically placed in a lead- ership role as a result of preparation at the advanced level. The knowledge base of the clinician is the foundation of clinical leadership and ultimately of other echelons as well. As a knowledgeable clinician, the APRN can lead collaborative teams for the improvement of care delivery and outcomes.
The healthcare system can also be an important arena for the APRN to lead. APRNs have a unique view of the patient, community, and healthcare system needs and thus can bring needed insight to the administration of hospitals, clinics, and other healthcare delivery formats. On the commu- nity, national, and international levels, the APRN can be involved and lead various professional organizations and influence healthcare policy. This is a very important area in which APRNs should be involved. It can be very time- consuming and frustrating, but ultimately very rewarding as APRNs advocate not only for improved healthcare but also for the nursing profes- sion. APRNs make a huge impact not only at the bedside but also by using that clinical knowledge to induce change.
The IOM report The Future of Nursing: Leading Change, Advancing Health (2010) emphasizes mentoring as an important part of the leadership role for APRNs. For example, APRNs can take the lead in fostering growth and promoting forward thinking in new or less- experienced nursing staff and APRNs. Some facilities or programs have introduced formal mentoring programs for nurse leaders. In these programs, a senior nursing leader will partner with a newer nursing leader for a period of time to guide the newer nursing leader in his or her role (Bally, 2007 ). It has also been suggested that APRN educational programs include more of a focus on leadership qualities. Superior leaders require not only a strong clinical background but also formal education on leadership models, behaviors, and commu- nication in interpersonal and large- scale formats (Adeniran, Bhattacharya,
& Adeniran, 2012 ). Bedside mentoring would be the most effective for the majority of APRNs. However, in our fast- paced system, new trends are emerging. Mentoring can take place via email, social networking sites, and blogs. Ultimately, however the relationship is carried out, it is most impor- tant to have a good rapport between the individuals and promote an open and caring environment for learning.
Advocacy for nursing directs the APRN to support other nurses in their professional growth and to contribute to the evolution of the nursing