As the advanced practice role emerges and evolves internationally, new opportunities for APRNs have emerged. As with previous editions, this text prepares APRN students for success in the multidimensional advanced practice role.
FOUNDATIONS OF
ADVANCED NURSING PRACTICE
OVERVIEW OF ADVANCED PRACTICE REGISTERED
Working across state lines results in even more complexity due to the laws and regulations of each state. In addition, each healthcare organization may interpret state and federal laws and regulations in its own professional human resources policies.
ADVANCED PRACTICE REGISTERED NURSING
Complex policies and laws require APRNs to routinely navigate insurance reimbursement, administration, and health policy. Given significant variations among practice settings, APRNs must be expert and proactive in business and regulatory policies and processes.
THEN AND NOW
Magaw's legacy is honored in the motto of the American Association of Nurse Anesthetists (AANA): Safe and Effective Anesthesia Care (AANA, n.d.). Of the 115 accredited nurse anesthesia programs in the United States, 39 are in a variety of non-nursing academic units (COA, 2017).
SUMMARY
Although the content of this chapter has focused on APRNs in the United States, it is encouraging to see the continued evolution of these roles in other countries. Midwifery, which is often distinct from nursing, has a longer history internationally than in the United States.
ACKNOWLEDGMENT
Nurse anesthetist education and training positions these advanced nurses to lead healthcare into the future. In countries such as Australia, Canada, Ireland, the Netherlands and New Zealand, nurses have become an important player in the health care system (Maier, Barnes, Aiken, & Busse, 2016), while the nurse specialist was one of the first roles of advanced nurses (APNs) developed in Asian countries (Pulcini, Jelic, Gul, & Loke, 2010).
The International Confederation of Midwives, so named in 1954, has more than 130 midwifery association members representing 112 countries (see www.internationalmidwives.org. Retrieved from https://www.bls.gov/ooh/healthcare/nurse-anesthetists - nurse- midwives and nurses.htm.
ADVANCED PRACTICE WITHIN A NURSING PARADIGM
So often the media has focused on the physical assessment skills, duties, and descriptive privileges of APRNs rather than on the special and unique knowledge, education, skills, and expertise that characterize advanced practice nursing. As advanced practice nursing moves rapidly toward the practice doctorate as an entry into practice, there is an excellent opportunity to reconceptualize how advanced practice nursing is taught in APRN programs.
WHAT IS NURSING?
The partnership between the nurse and the individual is evident in Nojima's definition of nursing. Other initiatives, such as Nursing Diagnoses and Human Responses, outline the substantive basis of nursing.
THE ART AND SCIENCE OF NURSING The Art of Nursing
Newman, Sime, and Corcoran-Perry (1991) noted that the focus of nursing is "care in the human health experience" (p. 3). A theory-based paradigm-centered advanced nursing practice defines and exemplifies many attributes of the APRN.
THEORETICAL AND CONCEPTUAL MODELS
In this regard, Smith (1995) stated the following: "The core of advanced nursing practice lies within nursing's disciplinary perspective on the human-environment and caring interrelationships that facilitate health and healing. One's conceptual perspective on clients and on the goals of nursing largely determines, what kinds of things are evaluated (Gordon, 2007; Johnson, 1959.
INCORPORATING NURSING INTO ADVANCED PRACTICE NURSING
The art of nursing is based on science, care and understanding of the human experience of health and illness. The doctor in nursing practice essential and new model for advanced practice nursing (2nd ed.
MULTIFACETED ROLES OF THE APRN
VERSATILE APRN ROLES. CNS) and certified registered nurse anesthetists (CRNA) may participate in these programs; Certified nurse-midwives (CNMs) were not included. Traditionally, APRN roles have been clinically focused, as clinician, patient advocate, case manager, and collaborator, to name a few.
APRN ROLES
Army defines “leadership” as “the process of influencing people by providing purpose, direction, and motivation to accomplish the mission and improve the organization” (Army Doctrine Publication, 2012, p. 1). The first is “Organizational and Systems Leadership for Quality Improvement and Systems Thinking.” The key here is to emphasize practice while working to improve health outcomes and patient safety on a practice-level or system-wide basis. The second essential regarding leadership is “Healthcare Policy for Healthcare Advocacy.” The DNP-prepared APRN has the capabilities to broaden the scope of nursing leadership and address policy issues in the public and nursing professions (Ehrenreich, 2002).
ADVANCED PRACTICE
NURSING WITHIN HEALTHCARE SETTINGS: ORGANIZATIONAL
THE U.S. HEALTHCARE SYSTEM
There are many factors involved, and these influences can clearly change over the course of an APRN's career. The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]), the Institute of Medicine (IOM), the Agency for Healthcare Research and Quality (AHRQ), and the US CMS IOM defines "healthcare quality" as "the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (p.
INTERPROFESSIONAL
COLLABORATIVE TEAMS AND EDUCATION: ROLES FOR
Medicine has traditionally remained at the top of the healthcare hierarchy, with all other healthcare professions considered second best (Price et al., 2014. With the continued evolution of the role of the APRN and Doctor of Nursing Practice (DNP), these old views and practice models are being challenged (Price et al ., 2014. Reconceptualizing the role of the APRN as a liaison between and among team members (Légaré et al., 2011) and as a care coordinator will clarify one function of the APRN within the team.
GLOBAL HEALTH: DYNAMIC ROLES FOR THE APRN/
GLOBAL APRN/APN ROLES AND TRENDS
A master's degree is recommended for entry level." The term "advanced practice nurse" (APN) is the generally accepted international term. The first recommendation of the report focused on removing the barriers to practice for APNs. The results of this meeting are detailed in a video from the Global Advanced Practice Nursing Symposium (Philadelphia, 2014), available at: https://.
BROADER GLOBAL TRENDS AND NEEDS
These objectives are listed in Table 6.2 (United Nations, 2018) and measurable objectives can be found at www.sdgfund.org/mdgs-sdgs. Membership is free and accessible through the network's website, www.icnapnetwork.org. More information can be found on the website. www.orgs.tigweb.org/funedesin-foundation-for-integrated-education-and-development.
ROLE OF THE APRN/APN IN GLOBAL RESEARCH
A list of necessary drugs/supplies to be purchased while in country should be compiled and then shared with the host to facilitate discounted purchases. A running list of recommendations for the next trip is another task for the team leader. The team leader may need to talk to people who have had traumatic experiences in the treatment of patients.
CONDUCTING GLOBAL RESEARCH
Although the APRN/APN role is well established in North America, the role continues to evolve internationally in both high-resource and low-resource countries, creating a research literature with an evidential and exploratory focus that is rich and in development.
ROLE OF THE APRN/APN IN EDUCATION DELIVERY AND CONSULTATION
Clear answers to these questions provide the basis for interactions and the focus of consultation. Resources for the consultant (office and living space, fees and communication assistance abroad and within the country through translators if necessary) should be discussed before the consultation begins. As the consultation draws to a close, everyone involved must evaluate the effectiveness of the project.
ACKNOWLEDGMENTS
The sustainability of projects emerging from the consultation process should be an important design consideration (Mullan & Kerry, 2014. Retrieved from http://www.haygroup.com/en/campaigns/the-six-global-megatrends-you - must- be-prepared-for/. Retrieved from https://journalistsresource.org/studies/society/public-health/global-rise-human-infectious-disease-outbreaks.
LEADERSHIP FOR
COMPETENCIES FOR
APRN: CHALLENGES AND OPPORTUNITY
Care transition management is another arena where APRNs have demonstrated outstanding leadership, particularly in the management of chronic disease management. Thus, leadership has been a critical driver in the development of the APRN role and will continue to be critical not only in role development but also in success in redesigning the health care system. In AACN, The Essentials for Doctoral Education for Advanced Nursing Practice (AACN, 2006) delineates the importance of management knowledge and skills throughout the document and specifically addresses management in Essentials II, VI, and VIII.
CLINICAL LEADERSHIP
No one is better qualified to manage this task in the work environment than nurses who have the education and knowledge of policies, regulations, culture and their work environment. A lack of leadership has been shown to be instrumental in the occurrence of supervisory events (Joint Commission, 2017. Given the primacy of leadership in the APRN role, much more work is needed in practice and even in countries to understand APRN leadership (Elliott, Begley, Sheaf, &.
HEALTHCARE ENVIRONMENT
APRNs can exercise leadership in the healthcare environment to improve outcomes in each of the domains of the Quadruple Aim through inspiration, innovation, and influence. Operationalizing leadership for each of the APRN roles within the healthcare setting does not have a clear definition, nor are there specific competencies. These high-level decision-making opportunities position APRNs to fully participate in the redesign of the health care system.
LEADERSHIP AND ADVOCACY FOR THE PROFESSION
Retrieved from http://www.aacnnursing.org/Education-Resources/AACN- Essentials American Association of Colleges of Nursing. Retrieved from https://www.aanp.org/press-room/press-releases/173-press-room/2017-press-releases/2098 -more-than-234-000-licensed-nurse-practitioners-in- the United States. Retrieved from https://www.beckersasc.com/anesthesia/3-key - thoughts- from- American- Association- of- Nurse- Anesthetists-incoming - President-Bruce-Weiner.html.
IMPLEMENTATION OF THE APRN ROLE
ADVANCED CLINICAL DECISION MAKING
DECISION- MAKING PROCESSES: RESEARCH IN CLINICAL REASONING
Clinical reasoning is the cognitive processes used to make a diagnosis and treatment plan (Pinnock, Young, Spence, Henning, & Hazell, 2015). Nursing clinical reasoning is based on the interconnectedness of intuition, analytical processes, context, and experience (Cappelletti , Engel, & Prentice, 2014. As you can see, there is significant overlap in clinical reasoning processes used in medicine and nursing.
COMMONALITIES IN CLINICAL REASONING ACROSS HEALTH DISCIPLINES
Advanced practice nursing involves a complex blend of nursing and medical clinical reasoning and decision making. One factor that can be used to differentiate clinical decision making in advanced nursing practice from other autonomous health care providers is the focus of APRN practice. An important feature of clinical decision making in advanced practice nursing is that the nursing focus continues to be evident in everyday practice.
CLINICAL DECISION MAKING AS UNDERSTOOD FROM PRACTICE
A research-based understanding of the relationships between critical thinking and clinical decision-making is not yet well developed. The complexity of the health care system and patients requires interprofessional collaboration and communication to ensure good clinical decision-making that results in patient-centered care (ten Ham, Ricks, Rooyen, & Jordan, 2017). The complexity of the health care system and patients requires interprofessional collaboration and communication to ensure good clinical decision-making that results in patient-centered care (ten Ham, Ricks, Rooyen, & Jordan, 2017).
HEALTHCARE POLICY
IMPLICATIONS FOR ADVANCED NURSING PRACTICE
Improving access to care is a key goal of the Center to Champion Nursing in America, a joint initiative of the Robert Wood Johnson Foundation (RWJF) and the American Association of Retired Persons (AARP). Their Campaign for Action (accessible at www.campaignforaction.org) is working nationally to implement the recommendations of the IOM report on the Future of Nursing: Leading Change, Advancing Health (2011). Similar to the map accessible on the NCSBN website, the AANP has a State Practice Environments map accessible at www.aanp.org/legislation-regulation/state-legislation/state-practice-environment.
LEADERSHIP AND HEALTH POLICY
Today more than ever, APRNs need to be informed by health care professionals who are aware of current health policy issues, the process needed to effect change, and the nursing and advanced practice nursing advocacy groups working to remove barriers and support. policies that enable them to provide the best care to their patients. The example of Florence Nightingale and her use of evidence to transform the health care systems of her time serves as a model for leadership in health policy development today. For many APRNs, moving from leadership in clinical practice to leadership in health policy is not an obvious choice.
PUBLIC POLICY: THE PROCESS
Bipartisan support in both the House and Senate was a highly unusual occurrence for this 113th session of Congress, “The Least Productive Congress Ever” (Cillizza, 2014). In the Senate, bills affecting each of these laws will be sent to the Senate Finance Committee. Through incremental changes, some aspects of the problem can be solved now, which will open the policy window for more comprehensive changes in the future.
THE APRN AS ENGAGED CITIZEN Scanning the Environment
American Association of Colleges of Nursing www.aacnnursing.org American Association of Critical Care Nurses www.aacn.org. Retrieved from http://www.washingtonpost.com/blogs/the- fix/wp president - Obama- said- the- 113th- Congress- is - the - Federal Trade Commission - the - least - productive - ever - it. Retrieved from http://www.ftc .gov/system/files/documents/reports/policy- outlook- competition- regulation- advanced- practice- nurses/140307aprnpolicypaper.pdf.
