NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice

NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice

No matter if your state allows for full practice, reduced practice, or restricted practice, NPs just as RNs are accountable for providing care according to their scope of practice. Mennella and Heering (2017) state “accountability is the primary outcome of all levels of professional nurse autonomy” (p. 1). According to Park, Athey, Pericak, Pulcini, and Greene (2018), 21 states and the District of Columbia allow NPs to practice independently and have full practice authority. In NJ NPs have reduced practice authority and must have physician’s sign off on certain care decisions. I worked in LTC in NJ, we had an NP that came in weekly and did wound rounds. She was able to make care recommendations, but we had to call the primary physician to write the order for the needed treatment.

CNP (Certified Nurse Practitioner)

• Provide primary health care services to pediatrics, families, and geriatrics. These NPs can diagnose and treat illness and injuries. They can prescribe medications and diagnostic tests. Depending on the state that the NP is employed they may have to work with a physician on certain aspects of patient care. (www.nursejournal.org)

CRNA (Certified Registered Nurse Anesthetist)

• Administer anesthesia care to patients. These duties include administering anesthesia during medical and dental procedures, follow-up care, pain management and inserting PICC lines. This is a highly skilled position and requires licensing from the American Association of Nurse Anesthetists. (www.anaa.com)

CNS (Clinical Nurse Specialist)

• Work in many areas of health care including acute care, home health, and community health settings. There knowledge and skills are used to apply theory and research to practice improving patient outcomes. In my hospital the CNS works with stroke and palliative care patients. They manage care of these patients and have the ability to prescribe care based on organizational protocols. (www.graduatenursingedu.org)

CNM (Certified Nurse Midwife)

• These NPs specialize in women’s reproductive health and childbirth. They provide preventative and health maintenance, family planning, and all aspects of childbirth. They provide holistic care to the women in their care. This NPposition can be stressful, emotional, and include long hours. (www.registerednursing.org).

APN Role     Median Salary
CNP                 $98,000
CRNA             $154,000
CNS                 $80,000
CNM                $91,000

A nurse pracitioner master’s degree program may not be practical for Jessica to complete if she is only given 2 years to complete the degree. Also, if she accepts the administrative position she may find it difficult to complete the intensive practicum required by most programs. However, if she chooses to enroll in a program, she would probably be most suited for a clinical nurse specialist program. In this position she can still have direct patient interaction and can make a positive impact on patient care and outcomes.

Thanks for reading,

ALSO READ: NR 510 Week 3: Organizational Behavior and Business Influences and Advanced Practice Nursing Case Study- Part One

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NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice Resources:

Certified registered nurse anesthetist fact sheet. (2017, October 10). Retrieved from https://www.aana.com/patients/certified-registered-nurse-anesthetists-fact-sheet.

Certified nurse midwife. (2017). Retrieved from https://www.registerednursing.org/nurse-midwife/.

Clinical nurse specialist (CNS). (2018). Retrieved from https://www.graduatenursingedu.org/clinical-nurse-specialist/.

How to become a CNP certified nurse practitioner. (2017). Retrieved from https://nursejournal.org/nurse-practitioner/how-to-become-a-certified-nurse-practitioner/.

Mennella, H. & Heering, H. (2017). Professional autonomy and advanced nursing practice. Cinahl Information Systems.

Nurse practitioner career guide. (2018). Retrieved from https://nurse.org/resources/nurse-practitioner/.

Park, J., Athey, G., Pericak, A., Pulcini, J., & Greene, J. (2018). To what extent are state scope of practice laws related to nurse practitioners’ day-to-day practice autonomy. Medical Care Research and Review, 75(1), 66-87.

I will admit that I have not looked a great deal at the liabilities of the various APN roles extensively, but I do have acquaintances in all of the 4 major areas we are discussing.  It is my opinion that the CRNA would face the most potential jeopardy simply based on the nature of their position and the ramifications of a mistake to the patient outcomes.  That said that, the role of APN is one which requires extreme care and carries the potential to do great harm to patients.  This harm can extend to not only what the NP does, but also to what they do not do.  In the emergency department where I work, the NP does work independently but does have to present their work to a doctor for verification.  The amount of verification is dependent on the reputation the individual has established for themselves based on how they perform their job.  I think that there would be implications for both the NP and the doctor who signed off on the treatment faced with litigation.  The APN does have a license and must protect themselves through due diligence in all matters of patient care.

I appreciate your honesty. I also feel that most NPs are not fully aware of the regulations governing practice in their respective states, nor are NPs fully aware of the liabilities associated with the various APN roles. Even if current and future NPs feel they are knowledgeable about both topics, regulations governing practice and liabilities, they should constantly educate themselves on these matters. In nursing, laws and acceptable practices change all the time. NPs must know the current laws guiding practice at all times. We already know that most physicians view NPs as a threat and that most insurance companies and state/federal policies regarding NPs scope of practice are slow to change; therefore, we must protect ourselves and our profession. The Oregon Nurses Association (2018) has re-posted an article by the Journal for Nurse Practitioners that discusses/gives an overview of APN/NP liability claims. The article contends since the NPs role in healthcare has broadened, it is important that NPs review liability claims to develop “useful risk-management strategies” (Oregon Nurses Association, 2018).

 

NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice References

Oregon Nurses Association. (2018). The journal for nurse practitioners’ article: “NP professional liability: A synopsis of the CNA heal. Retrieved from http://www.oregonrn.org/?389

Advanced Practice Nurse Scope of Practice

The scope of practice of nurse practitioners is dependent on the state in which one applies for licensure. The scope of practice can be classified as full practice, reduced scope, and restricted scope practice. Currently across the US, most states have either restricted or reduced the scope of practice for nurse practitioners. Only 21 of the states offer nurse practitioners a full scope of practice. In Illinois, nurse practitioners are licensed to practice independently or in collaboration, or under other health care providers.

Educational Requirements

A prospective Advanced Practice Nurse must be a holder of RN licensure. He or she must be a graduate degree or a post-master certificate holder. The other prerequisite is that he or she must hold a certificate in advanced practice in any of the four advanced practice roles certified in Illinois (Illinois APN Requirements | Become a Nurse Practitioner in IL – NursingLicensure.org, 2020). Subspecialty advanced practice nursing is also acceptable when one desires to complete a second degree.

License Requirements

Illinois still practices examination-based certification before licensure. Certification is the sole purpose of corresponding bodies such as the midwives association, and anesthetists association. Nurse Practitioners hold certification from boards like the  American Academy of Nurse Practitioners Certification Program and the  American Nurses Credentialing Center among others. Licensure is done by the Illinois Department of Financial and Professional Regulation (IDFPR) and the Illinois Board of Nursing. The official graduation transcripts are a requirement before licensure. The licensing application costs  $125 (Illinois APN Requirements | Become a Nurse Practitioner in IL – NursingLicensure.org, 2020). License renewal is done on a two-yearly basis so long as the APRN maintains certification.

Regulatory Requirements

The Illinois Department of Financial and Professional Regulation (IDFPR) regulates the practice of nurse practitioners. For license renewal, the NP must have completed 80 hours of continuing medical education.  License renewal is two years and costs $80.00 (Illinois Department of Financial and Professional Regulation, 2020). For re-licensure, the certifications of advanced practice must be maintained.

Practice Authority

Illinois has a restrictive law on the practice authority of nurse practitioners. Initially, Nurse Practitioners have to work under physician oversight. Licensing for practice authority requires a nurse practitioner to provide evidence of completion of at least 250 hours of training or continuous medical education or proof that they have at least 4000 hours of experience in the clinical setup (APRNs Granted “Full Practice Authority” in Illinois, 2020). An APRN license is also needed. These are the prerequisites for full practice authority.

Prescriptive Authority

Prescriptive authority is a jurisdiction that provides a healthcare provider with the sovereignty to prescribe medication to patients. The prescriptive independence of nurses has long remained a contentious issue and due to variations of this law in different states in the US, it remains complicated (Jiao et al., 2018). The legal aspects of prescriptive autonomy in Illinois are managed by the Illinois Department of Professional regulation. In the state of Illinois, Nurse practitioners lack complete independence hence they must be oversight by a physician. The laws require Nurse Practitioners to have a mid-level practitioner controlled substance license to have some prescriptive independence for controlled substances which is obtained by supplying a notice filled by a physician (Illinois General Assembly – Full Text of Public Act 096-0189, 2020). Generally, NPs can prescribe under a physician’s instruction. Retaining the licensure on prescription requires a regular renewal of the license and a good reputation. These hurdles in prescriptive authority are meant for ultimate patient safety and high-quality care.

 

Nurse Practitioner Core Competencies

The National Organization of Nurse Practitioner Faculties (NONPF) enlists a set of 10 domains of competencies for Nurse Practitioners. Each domain depicts a set of skills that a nurse practitioner needs to have. These competencies are aligned with the AACN essentials. These competencies are useful in the development of curricula for postgraduate studies. They include competencies in the domain of knowledge for nursing practice, patient-centered care, population health, scholarships for nursing disciplines, quality and safe care, partnerships across different professions, systems-based practice, professionalism, informatics, and health care technology application, and personal and leadership development (American Association of Colleges of Nursing, 2021).

 

Personally Strong competency Areas

After a detailed review of the ten competencies of a nurse practitioner, I can confidently mention that interprofessional partnerships are the real deal for me. Generally, I am a very outgoing person.  As early as high school, I have had a great interest in statistics, finding out why things occur in some pattern, and remedies that can be put in place to alleviate suffering. This has over time pulled me into research. Through research, I partner with organizations and individuals in a quest to make life bearable. I collaborate with physicians, pharmacists, and laboratory technologists among others to actualize studies that have been useful in the formulation of policies that guide practice. My second competency is in individualized patient-centered care. I am a strong advocate for both evidenced based practice and culturally competent care. My love for humanity knows no bounds. This puts me at a vantage point to ensure patient satisfaction in the process of provision of care. I am a fierce patient advocate. I have been that fierce since I began my practice. According to Karaca & Durna, (2019) patient satisfaction improves the outcome and reduces readmission rates. At my former workplace, I introduced a survey for patients’ level of satisfaction with the care provided. This helped us improve our areas of weakness as an organization.

Competency Areas Where There is Room for Growth

I have also noted two areas in which I should improve my competencies. The first domain is Informatics and Healthcare Technologies. For a long time, I have viewed the Information Technology aspect of healthcare as a very hard concept. Healthcare is for sure revolutionizing health care and I risk being left behind. Aspects like mHealth, telemedicine, and electronic health records are important new developments. I feel like this domain has such a high level of essentiality even for my endeavors in research studies. Electronic health records allow for timely access to data for studies (De Benedictis et al., 2020). The second area where there is room for growth is leadership. I have an immense loathing for the process of politics. This notion has for a long time made me view leadership as a secondary issue in my life. I have learned that through leadership, policies are influenced. These policies could be great ideas to improve the quality and safety of care. I have it in my plan to join the American Association of Nurse Practitioners (AANP) to help me nurture my skills in this domain of leadership. My expansive interactions with individuals in the nursing profession and beyond the profession have helped me view myself as a great organizer which is one of the strengths required in leadership.

Scholarly Activities to Help Achieve NP Competencies

I would want to continue improving on my weakness and soaring on my strengths. I am a member of the American Nurses Association.  It is in my plans to join the American Association of Nurse practitioners. I have participated in research studies, and done an article in collaboration with my friends which is yet to be published. This is certainly a good foundation that I would like to build on. With my interest leaning more toward research, I have planned to join a few nurse professional organizations which focus on research. Joining these organizations brings me closer to like-minded professionals who can help me grow my leadership skills. I have made steps towards embracing the informatics aspect of health. I have planned to pursue a short course in health informatics soon. I have a mentor that inspires me to pursue my plans. I would someday like to be an inspiration to people. This thought keeps me alive and has helped me accomplish my plans.

           

Leadership Skills

Leadership Skills Required to Lead in Complex Systems

Nurse Practitioner is a high cadre in nursing. This makes an NP to be looked up to for guidance on a myriad of issues from time to time. This calls for a nurse practitioner to be equipped with leadership skills. Communication is the first skill and one of the most important skills me. Proper communication is a critical skill in ensuring the success of a unit. It allows the leader to exercise empathy with both patients and nurses. Communication is a major factor in job satisfaction for nurses (Jankelová & Joniaková, 2021). Other skills include critical thinking which is essential in problem-solving. Lastly, organizational management skill is crucial to both the success of the hospital organization and patient satisfaction.

Strategies to Help Develop NP Leadership Skills

Learning is the first step to developing leadership skills. Learning can be done from the observation of role models. Learning can also be actualized by taking a course on leadership. Perfection of skills is through practice in day-to-day interactions (Johnson et al., 2020). Situational awareness and discernment are often successful strategies in the development of skills.

 

NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice Conclusion

As the nursing profession advances, there is a need to have more subspecialties in nursing. This calls for professional development and educational advancement. Just like all health professionals, licensing and certification are important. This serves as a safeguard for safety and quality in patient care. The knowledge of competencies and weaknesses will help shape me into the professional that I would want to be. I will capitalize on the insights I have gained thus far to help me design a clear path in career development.

NR 510 Week 1: Historical Development of Advanced Practice Nursing and Evidence-Based Practice References

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf

APRNs Granted “Full Practice Authority” In Illinois. (2020, November 24). Www.mbhealthlaw.com. https://www.mbhealthlaw.com/aprns-granted-full-practice-authority-in-illinois#:~:text=In%20order%20for%20an%20APRN

De Benedictis, A., Lettieri, E., Gastaldi, L., Masella, C., Urgu, A., & Tartaglini, D. (2020). Electronic Medical Records implementation in hospital: An empirical investigation of individual and organizational determinants. Plos One, 15(6), e0234108. https://doi.org/10.1371/journal.pone.0234108

Illinois APN Requirements | Become a Nurse Practitioner in IL – NursingLicensure.org. (2020, November 4). https://www.nursinglicensure.org/np-state/illinois-nurse-practitioner/

Illinois Department of Financial and Professional Regulation, (2020). https://nursing.illinois.gov/PDF/2020-02_IL_APRN_CE_Relicensure_FAQ.pdf

Illinois General Assembly – Full Text of Public Act 096-0189. (2020). Www.ilga.gov. Retrieved November 6, 2022, from https://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=096-0189&print=true&write=

Jankelová, N., & Joniaková, Z. (2021). Communication Skills and Transformational Leadership Style of First-Line Nurse Managers in Relation to Job Satisfaction of Nurses and Moderators of This Relationship. Healthcare, 9(3), 346. NCBI. https://doi.org/10.3390/healthcare9030346

Jiao, S., Murimi, I. B., Stafford, R. S., Mojtabai, R., & Alexander, G. C. (2018). Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 38(4), 417–427. https://doi.org/10.1002/phar.2095

Johnson, O., Begg, K., Kelly, A. H., & Sevdalis, N. (2020). Interventions to strengthen the leadership capabilities of health professionals in Sub-Saharan Africa: a scoping review. Health Policy and Planning, 36(1), 117–133. https://doi.org/10.1093/heapol/czaa078

Karaca, A., & Durna, Z. (2019). Patient satisfaction with the quality of nursing care. Nursing Open, 6(2), 535–545. https://doi.org/10.1002/nop2.237\

Mlambo, M., Silén, C., & McGrath, C. (2021). Lifelong learning and nurses’ continuing professional development, a meta-synthesis of the literature. BMC Nursing, 20(62), 1–13. https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-021-00579-2

The article by Hain and Fleck (2014) describe multiple barriers to APN practice. State practice and licensure is identified as a challenge as each state has its own guidelines that outline an NPs scope of practice (Hain & Fleck, 2014). This does not allow for a general standard of care expected for NPs to evaluate and diagnose patients, order diagnostic tests or initiate and manage treatment plans.  Approximately 20 states grant NPs full practice authority licensure, which allows NPs to practice independently of a physician or hospital. Most states reduce the NPs practice and licensure, which means NPs can either engage in at least one element of the NP practice through a collaborative agreement or with an outside health discipline or under supervision of a physician (Hain & Fleck, 2014). The next challenge the article mentions is physician related issues. The problem here is that physicians do not feel NPs have received enough training or education to administer the same type of treatment as a doctor. Physicians are also confused about the role of nurse practitioners in a collaborative environment (Hain & Fleck, 2014). Physicians may feel there is no need for the NP to advise the patient if the physician (especially if a medical specialist is present). Other barriers mentioned are payer policies, job satisfaction, and restrictions in admitting and prescriptive privileges. Since nursing services have traditionally been tied into the institutional room fee or other professional fees on a patient’s billing statement, nursing services are not considered “billable” (Hain & Fleck, 2014). Nurses often cite having little autonomy over practice and limited career advancement opportunities as reasons for leaving the profession (Hain & Fleck, 2014).

I am not surprised about the barriers presented in the article. I believe the majority of concerns center on accountability and skill level. The article by Hain and Fleck (2014), states NPs can help reduce the primary care provider gap but that allowing NPs full practice authority may cause patients to choose between being seen by a physician or NP. I understand this point of view, but I believe patients are astute enough to know when to see a specialist for a condition versus opting for services provided by an NP. I also see a great deal of disrespect displayed by doctors toward nurses simply because physicians have more medical training than NPs. The lack of collaboration may stem from a lack of trust or mutual respect (Schadewaldt, McInnes, Hiller, & Gardner, 2013). A number of factors influence the functioning or failure of collaboration between NPs and MPs, such as funding issues, traditional role allocation, legislation, personal attitudes toward collaboration, and organizational structures (Schadewaldt et al., 2013). NPs must hold a four-year degree, have years of practice experience, obtain a graduate degree, pass multiple certification exams, and pursue further specialization. While new roles for NPs present opportunities, NPs are unsatisfied with their work roles because they lack autonomy and respect (Schadewaldt et al., 2013).

These barriers represent restraint of trade because NPs are not allowed in over 29 states to practice without restrictions imposed by state nursing licensing boards. Since NPs must go through rigorous training to become just as qualified as a physician to administer medical services, they should be allowed to practice. However, one of the reasons Hain and Fleck (2014) state NPs are not allowed this professional courtesy is physicians may feel some sort of competition toward them. Physicians do not want to lose revenue.Nurses can influence these barriers by joining powerful nursing organizations that promote and advocate the rights of NPs. Nursing practitioners can also become more involved in the legislative process. NPs can also become influential members of state nursing licensing boards and lead the vote to change current standards.

 

References:

Hain, D., & Fleck, L. (2014, May). Barriers to nurse practitioner practice that impact healthcare redesign. OJIN: The Online Journal of Issues in Nursing, 19, 2. Manuscript 2. Retrieved from doi: 10.3912/OJIN.Vol19No02Man02

Schadewaldt, V., McInnes, E., Hiller, J. E., & Gardner, A. (2013). Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care – an integrative review. BMC Family Practice, 14, 132. Retrieved from http://doi.org/10.1186/1471-2296-14-132