For the past nine years, she has practiced in the Movement Disorders Center at the Neurological Institute at Columbia University Medical Center. Subsequent sections of the book discuss the DNP approach to specific patient populations.
THE EMERGENCE OF THE NURSE PRACTITIONER MODEL
At the same time, national health care policy was undergoing a dramatic change that would prove to be one of the most fortuitous events in advanced practice nursing. The nursing practice model, originally developed for community nurses, quickly became associated with primary care and, with the rapidity of all ideas emerging in a time of need, moved to rural and inner-city areas, where these newly trained NPs became primary care providers.
NURSES MOVED INTO PRIMARY CARE AS PHYSICIANS MOVED OUT
It is truly difficult to be a fully engaged and funded researcher actively publishing and developing new science, as well as being an active modern clinician mentoring novice clinicians. Many schools wanted to have PhD faculty, in line with other health professions schools, but found that researchers were not best suited (or most prepared) to be clinical supervisors, and students could find that their supervisors were not fully engaged or current in clinical endeavor.
COLUMBIA UNIVERSITY SCHOOL OF NURSING’S MODEL OF CLINICAL EDUCATION
Even with all these building blocks in place and the benefits clear to all players, such a radical change in the practice environment of an academic health center required visionary, big-hearted physicians and courageous, smart nurses who all agreed to be measured against existing standards and values. - standards.
PARTICIPATION OF FACULTY NPS IN A RANDOMIZED CONTROLLED TRIAL
ESTABLISHMENT OF FACULTY PRACTICE: CAPNA
THE COLUMBIA DNP MODEL, COLLABORATION ON THE CREATION OF CACC, AND THE AACN ESSENTIALS
In 2003, representatives from eight schools of nursing councils published the competencies that a DNP graduate should achieve (CUSN, 2003). In 2005, the council changed its name to the Council for the Advancement of Comprehensive Care (CACC) to reflect the understanding that DNP clinical education encompasses a broader set of skills and knowledge than just primary care.
COMPREHENSIVE CARE CERTIFICATION EXAM FOR DNP GRADUATES
While the CACC focuses on direct patient care as "practice," the AACN DNP Essentials apply to DNP programs developed in areas of "practice" other than the clinical area. While an inclusive stance by an organization representing all collegiate nursing schools—the vast majority of which have no faculty prepared to develop an advanced clinical practice training program—is understandable, this lack of distinction between the DNP's direct care (practice) competency is blurred. and potentially weakened the public's understanding of who a DNP is and what this professional can do.
FIRST PHASE OF COMPETENCY DEVELOPMENT
The faculty NPs in the RCT were indistinguishable from the physician group in terms of accountability to patients. The faculty NP role with extended responsibility and accountability provided the model upon which the extended care competencies and the CUSN DNP program were built (Smolowitz & Honig, 2008).
SECOND PHASE OF COMPETENCY DEVELOPMENT
THIRD PHASE OF COMPETENCY DEVELOPMENT
CACC members conceptualized the doctor of nursing practice (DNP) as a clinician with the necessary skills, education, and abilities, as identified in the IOM definition of primary care, to provide comprehensive care to maintain and improve the health status of patients over time and across sites. Deans of nursing schools who were members of CACC and leaders in the national movement to introduce the clinical doctorate, committed to standardization without prescription, nominated one of their faculty members to serve on the Consensus Committee for DNP Credentials.
FOURTH PHASE OF COMPETENCY DEVELOPMENT
CACC members who had discussed delivery of comprehensive care used the Institute of Medicine (IOM) (1996, p. 1) definition: “the provision of integrated, accessible health services by clinicians responsible for addressing a large majority of personal health care needs, developing an ongoing partnership with patients and practicing in the context of family and community." This definition emphasizes prevention, risk assessment, cultural competence, and coordination of services for a diverse patient population. They envisioned the DNP as an expert clinician, trained to address the health challenges created by an increasing number of complex and chronic health conditions, the growth of information and biomedical technology, the aging and increasingly diverse population, and identified disparities in care.
FIFTH PHASE OF COMPETENCY DEVELOPMENT
As a result of the review process, the consensus committee agreed that the competencies represented core competencies for advanced nursing at the doctoral level. Smolowitz, was charged with re-evaluating the 2003 competencies in light of the experiences of CUSN DNP graduates and examples of health professional competencies, including the Outcome Project of the Accreditation Council Graduate Medical Education (ACGME, 2007), the Royal College of General Practitioners guide (RCGP, 2009) and the draft of the American Association of Colleges of Nursing Essentials (AACN, 2006).
SIXTH PHASE OF COMPETENCY DEVELOPMENT
SEVENTH PHASE OF COMPETENCY DEVELOPMENT
EIGHTH PHASE OF COMPETENCY DEVELOPMENT
- DNP Comprehensive Care Competencies
- COMPREHENSIVE CLINICALCARE Competency 1. Evaluate patient needs based
- COMPREHENSIVE CLINICAL CARE Competency 2. Evaluate population or
- COMPREHENSIVE CLINICALCARE Competency 3. Formulate differential
- DNP Comprehensive Care Competencies (Continued) (Continued)
- COMPREHENSIVE CLINICAL CARE Competency 4. Appraise acuity of patient
- COMPREHENSIVE CLINICAL CARE Competency 5. Evaluate and direct care during
- COMPREHENSIVE CLINICAL CARE Competency 6. Direct comprehensive care for
- COMPREHENSIVE CLINICAL CARE Competency 7. Facilitate and guide the
- INTERDISCIPLINARY AND PATIENT- CENTERED COMMUNICATION
- SYTEMS AND CONTEXT OF CARE Competency 1. Construct and evaluate
- SYSTEMS AND CONTEXT OF CARE Competency 2. Evaluate gaps in health care
- SYSTEMS AND CONTEXT OF CARE Competency 3. Synthesize the principles of
- SYSTEMS AND CONTEXT OF CARE Competency 4. Integrate principles of
- BUILIDNG AND USING EVIDENCE FOR BEST CLINICAL PRACTICES AND
Sammenligning af Columbia University School of Nursing DNP-kompetencer i Comprehensive Care, AACN Essentials og NONPF Practice Doctorate Nurse Practitioner Entry-Level Competencies. University of Texas Health Sciences Center ved Houston School of Nursing Yale University School of Nursing.
DOCTOR OF NURSING PRACTICE COMPETENCIES FOR COMPREHENSIVE CARE
The CUSN competencies of a nurse in comprehensive nursing (see table 2.1) form the framework for the curriculum and are integrated throughout the course and the internship. The American Association of Colleges of Nursing (AACN) published The Essentials of Doctoral Education for Advanced Nursing Practice (2006), and the National Organization of Nurse Practitioner Faculties (NONPF) published Practice Doctorate Nurse Practitioner Entry-Level Competencies (National Organization of Nurse Practitioner Faculties) 2006).
THE DOCTOR OF NURSING PRACTICE
In addition, the curricular content of the DNP program is mapped against the CUSN competencies to ensure that all competencies are adequately addressed. Students have academic and clinical experiences focused on one or more of the competencies.
AS A COMPREHENSIVE HEALTH CARE PROVIDER
Doctor of the Nursing Practice Comprehensive Care Competencies and Performance Objectives for Direct
Formulate a plan that addresses health promotion, anticipatory guidance and/or disease prevention for the individual. Develop a plan that addresses health promotion, anticipatory guidance and/or disease prevention for the family.
DIRECT CARE COMPETENCIES AND PERFORMANCE OBJECTIVES
Initiates referral to other health care professionals while maintaining primary responsibility for patient care in a subacute setting. Facilitate and guide the process of palliative care and/or end-of-life care planning by discussing diagnoses and prognosis, clarifying and validating patient wishes and priorities, and promoting informed choices and shared decision-making by patient, family and health care providers. care team
PORTFOLIO: THE TERMINAL SCHOLARLY PROJECT
The publication Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) recognized the direct care role for APNs. AACN and NONPF, leaders in nursing education, echoed the IOM's recommendations and published guidelines and strong position papers in support of doctoral programs that prepare APNs with the necessary skills and competencies to provide comprehensive care.
CLINICAL CASE NARRATIVES
The next part of this chapter presents the format and components of a clinical case narrative. CUSN faculty standardized this format to facilitate the process of writing and evaluating clinical case narratives.
GENERAL CLINICAL CASE NARRATIVE FORMAT
Each clinical case narrative consists of actual patient encounters that occur during the residency. In this example, the DNP resident listed the competency and only those performance objectives that were met in the case narrative.
DOMAIN 1, COMPETENCY 1
Each case narrative begins with a paragraph that discusses the reason for case selection, the total number of encounters in the narrative, the type of setting (outpatient, home, acute, specialty practice, primary practice, etc.), the type of insurance (commercial, Medicaid, Medicare, self-employed) and the competency or competencies addressed by the case study. When appropriate for part of the case narrative, a detailed discussion of the DNP resident's thought processes is included as a critical appraisal section in abox. Critical appraisal can be particularly important for ethical debate or where controversial or ambiguous evidence is involved.
EVIDENCE-BASED PRACTICE
The PICO Question
Formulating the PICO question is relatively easy for most clinicians who identify clinical practice questions many times a day. Thus, formulating the PICO question is an iterative process that is often clarified during step 2, identifying the evidence.
Identify the Evidence
- Examples of PICO Questions for Specifi c Question Types
Furthermore, well-designed decision support systems have been shown to facilitate guideline adoption and prevent medical errors (Garg et al., 2005). Several of the web-based pre-assessed resources (syntheses, synopses and summaries) have methods for characterizing study quality.
Critically Appraise the Evidence
- CEBM Levels of Evidence
However, adoption of decision support systems has been slow because development of such systems requires a large investment by healthcare organizations in time, expertise and money; therefore, these systems are not likely to be ubiquitous for some time yet (Jha et al., 2009). Of these calculations, the most important estimate is Source: Oxford Center for Evidence-Based Medicine Levels of Evidence (Philips et al., 2009).
Apply the Evidence
To understand and interpret the results reported in a research study, one must thoroughly understand the concept of statistical significance. Although understanding statistical significance is a central part of the curriculum, it is clearly reinforced that statistical significance does not imply clinical significance, preserving the patient-centeredness of EBP.
Evaluate the Practice Change
- CUSN DNP Competencies for Direct Patient Care Residency Case Narrative Log
- CUSN DNP Competencies for Direct Patient Care Residency Case Narrative Log (Continued)
For example, another competency that requires evaluating population or geographic health risk using principles of epidemiology, clinical prevention, environmental health, and biostatistics is evident from a narrative that assesses a patient and family at risk for a disease—recognizing a condition using epidemiologic principles or environmental factors (e.g., relative risk of asthma in an urban manufacturing district)—and/or assessing the patient and family with the disease (e.g., three out of four young children with asthma and a grandmother with chronic obstructive pulmonary disease, all living in overcrowded, substandard urban housing) and identifying associated epidemiological or environmental factors acting on the situation. Construct a culturally sensitive intervention that addresses the patient's needs in the context of the family and community.
HISTORY STYLE
This chapter focuses on the components of the comprehensive and interval history and complete physical examination necessary to develop a differential diagnosis, assessment, and plan of care for pediatric patients. Comprehensive, family-centered, continuous care of pediatric patients is challenging and utilizes multiple skill sets.
HISTORY AND DEVELOPMENTAL STATUS
PHYSICAL EXAMINATION
Listening to a song while looking in the ear or finding empty spots in the belly puts the child and parent at ease with the exam. Often, in the very young child, it is advisable to assess the heart sounds before the child develops fear and cries.
ASSESSMENT AND DIFFERENTIAL DIAGNOSIS
Role-playing at home with a medical kit can help these children be more receptive to a physical exam. Close observation of the child during the visit can provide important data about the child's general neurological and musculoskeletal status.
PATIENT-CENTERED PLAN
Inadequate health literacy is a hidden problem because many patients are afraid to admit their lack of understanding to health care providers (Baker et al., 1996; Parikh, Parker, Nurss, Baker, & Williams, 1996). Also, the DNP should individualize written and oral education to the level and language of the patient and family.
DOMAIN 1, COMPETENCY 2
DOMAIN 1, COMPETENCY 3
DOMAIN 3, COMPETENCY 2
ENCOUNTER CONTEXT
I reinforce to the patient that laboratory test results for sexually transmitted infections are for medical purposes and will not be submitted to the sexual offense evidence package. Hepatitis B vaccination should be given to victims of sexual assault at the time of the initial screening if they have not been previously vaccinated.
COMPETENCY DEFENSE
Sexually transmitted infectious disease; prophylaxis – victim of sexual aggression: 125 mg IM as a single dose plus metronidazole 2 g orally as a single dose plus either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. Sexually transmitted infectious disease; prophylaxis – victim of sexual aggression: 2 g orally as a single dose plus ceftriaxone 125 mg IM as a single dose plus either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days.
DOMAIN 1, COMPETENCY 4
Discuss the rationale for the diagnostic evaluation with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, compliance and effectiveness. Discuss the rationale for the therapeutic intervention with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, compliance and effectiveness.
DOMAIN 1, COMPETENCY 5
Formulate a differential diagnosis for a patient presenting with ambiguous or incomplete data, complex diseases, comorbid conditions, and possibly multiple diagnoses.
DOMAIN 3, COMPETENCY 1
DOMAIN 2, COMPETENCY 1
The patient states that he touched his scalp and there was a little blood in the area above the right ear. The patient tolerated the procedure well and was transferred to the PICU after recovery in the postanesthesia care unit (PACU).
DISCHARGE INSTRUCTIONS
The responsibilities of pediatric health care providers to their pediatric patients are appropriately mediated by respecting parental autonomy and parental responsibilities to enhance the well-being of their children. Respect for parental autonomy is conditioned by parents' agreement to meet the basic health needs of their children (Twiss, 2006).
CASE ADDENDUM
I have selected this case to document the comprehensive management of a pediatric patient diagnosed with a rare congenital lung anomaly who presented with respiratory distress in the neonatal period. Assess the acuity of the patient's condition and determine the most appropriate hospital treatment setting based on the level of acuity.
SUMMARY OF CARE PREVIOUSLY PROVIDED Prenatal
Infant F is a Caucasian male neonate with respiratory distress presenting with tachypnea, intercostal retractions, and abdominal grunts at six hours of age. Baby F is a 41-week AGA male newborn with mild respiratory distress at six hours of life.
CASE SUMMATION
The parents were made aware of the possible autosomal-dominant inheritance pattern of CLE, and the fact that the course of treatment will not be changed on the basis of genetics. Evaluate gaps in access to health care that compromise optimal patient outcomes and apply current knowledge about the organization and financing of health systems to mitigate the negative impact.
DOMAIN 3, COMPETENCY 3
Her last period was "two months ago." She had unprotected sex with the same partner in the last three months. Thus, she would have a reasonable explanation for the parents without informing them about the termination of the pregnancy (D2, C1, PO A).
THE DOCTOR OF NURSING PRACTICE AND CHRONIC ILLNESS CARE
It is the most expensive system in the world, yet health care outcomes are not commensurate with costs.
CHRONIC ILLNESS
BEHAVIORAL CHANGE
MOTIVATIONAL INTERVIEWING
Rather than directing the patient to examine behavior change itself, motivational interviewing attempts to direct the examination of ambivalence toward change so that the patient can come to his own conclusions when he is ready.
CHRONIC ILLNESS MANAGEMENT IN COMPREHENSIVE CARE
THE DNP UTILIZING THE CHRONIC CARE MODEL
The DNP can incorporate the above guidelines in establishing the ideal type of practice encouraged by the IOM.
THE PATIENT-CENTERED MEDICAL HOME
Design differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientific evidence, safety, cost, invasiveness, ease, acceptability, adherence and efficacy for patients facing new conditions and those with ambiguous or incomplete data, complex diseases, comorbidities conditions and multiple diagnoses in all clinical settings. Discuss the rationale for diagnostic evaluation with attention to scientific evidence, safety, cost, invasiveness, ease, acceptability, adherence, and efficacy.
DOMAIN 2, COMPETENCY 2
A genetic susceptibility to ketosis-prone DM has been suggested, but it is uncertain whether there are multiple genetic markers or just one major gene leading to a defect in b-cell secretion (Mauvais-Jarvis et al., 2004). . Ketosis-prone patients demonstrate that the presence or absence of islet cell autoantibodies or HLA susceptibility alleles is not necessarily a key determinant of b-cell function (Balasubramanyam et al., 2006).
