Summary Role Development for the Nurse Practitioner

Historical Perspectives: The Art and Science of Nurse Practitionering Julie G. Stewart U.S. News and World Report (2017) lists nurse practitioner (NP) as the second top occupation for 2017. There were 23,000 new NP graduates in 2015 who joined the ranks of the nation’s roughly 234,000 NPs, a number that has almost doubled within 10 years (American Academy of Nurse Practitioners [AANP], 2017). In 2010, the Institute of Medicine (IOM) released a report that identified the need for nurses to be placed at the forefront of health care. The report strongly recommended that advanced practice registered nurses—including nurse practitioners—be allowed to practice to the full scope of their abilities and that barriers be removed to enable moving forward. We have come a long way since 2010, but there are still milestones to reach and barriers to break. Nurse practitioners reached a tipping point as a profession (Buerhaus, 2010). Malcolm Gladwell states that the “tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire” (Gladwell, 2000, p. 12). Nurse practitioners have been given the opportunity to shine and to experience growth professionally. Nurse practitioners provide a solution to some of the issues affecting health care in America today. The need for NPs is growing as we consider the IOM’s recommendation and the large population of aging baby boomers, which is anticipated to increase the use of the healthcare system (DHHS, 2011; Van Leuven, 2012). In addition, the Patient Protection and Affordable Care Act signed in 2010 instituted comprehensive health insurance reform and expanded healthcare insurance coverage to 32 million Americans (DHHS, 2011). Researchers have validated the cost, quality, and competence of NPs’ role in providing primary care with outcomes that are similar to primary care physicians (Hamric, Spross, & Hanson, 2009; Laurant et al., 2005; Mundinger et al., 2000; Wilson et al., 2005). Medical economist and health 3 CHAPTER 1 futurist Jeffrey C. Bauer (2010) reviewed evidence-based data in an article to illustrate how NPs functioning independently can meet the cost-effective needs of healthcare reform while providing high-quality care for patients in multiple settings. Indeed, more than 1 billion patients visit NPs for health care annually (AANP, 2017). At least 85% of NPs are educated to provide primary care, and two out of three are educated as family NPs (AANP, 2017); however, in some states, many NPs are not working in primary care possibly because of the state’s restrictions on requiring collaborators and written agreements with physicians. Many states have recognized this barrier and have removed those requirements, and many insurance companies are including NPs in their provider networks. So, will we meet the near future needs for healthcare providers? The answer appears to be a resounding yes. In an age-cohort, regression-based model, RAND Health projected the future workforce of NPs will grow to 244,000 by the year 2025 (Auerbach, 2012), and as previously mentioned, we are already more than 234,000 strong. Clearly, there is a need to fully understand the role of the NP in order to advance professionalism and unity of the NP workforce. Seminar discussions regarding pertinent issues must be part of the education of student NPs and included in discussion among those already in practice. ▸ Historical Perspective The role of the nurse practitioner was developed as a way to provide primary care for the underserved. The role is typically described as having emerged during the 1960s, yet Lillian Wald’s nurses of the late 1800s bear a striking resemblance to NPs of today. The nurses of Wald’s Henry Street Settlement House in New York City provided primary care for poverty-stricken immigrants, and treated common illnesses and emergencies that did not require referral (Hamric et al., 2009). In 1965, the role of nurse practitioner was formally developed by Loretta Ford, EdD (nurse educator), and Henry Silver, MD (professor of medicine), both of whom were teaching at the University of Colorado (Sullivan-Marx, McGivern, Fairman, & Greenberg, 2010). This nurse practitioner pro- gram was developed not only to advance the nursing profession; it was also developed in response to the need for providers in rural, underserved areas. The program was initially funded by a $7,000 grant from the School of Medicine at the University of Colorado (Bruner, 2005; Weiland, 2008). The first program was a pediatric NP program based on the nursing model, yet the program advanced the clinical practice of these students by teaching them how to provide primary care and how to make medical diagnoses. These early NP pioneers were focused on having a positive effect on advancing the profession, “making a difference,” and gaining autonomy (Weiland, 2008, p. 346). However, due to the socioeconomic and political climate of the times, the NP was viewed to be a cost-effective way to provide healthcare providers for the underserved. During the 1970s, federal funding helped to establish many NP programs to address a shortage of primary care physicians, particularly in underserved areas. Idaho was the first state to endorse nurse practitioners’ scope of practice to include diagnosis and treatment in 1971. NP programs doubled between 1992 and 1997. By the year 2000, there were 321 institutions that offered either a master’s level or a postmaster’s-level NP program (Health Resources and Services Administration [HRSA], 2004). By 2002, more than 30% of NPs were working with vulnerable populations, including the homeless, indigent, chronically ill, and elderly (Jenning, 2002). Today there are more than 400 institutions educating nurse practitioners, and 234,000 licensed nurse practitioners in the United States (AANP, 2017). 4 Chapter 1 Historical Perspectives: The Art and Science of Nurse Practitionering ▸ Nurse Practitioner Education and Title Clarification In the 1960s, the role of the NP was not warmly welcomed by nurse educators; therefore, many educational programs to train nurses in the NP role were more often continuing education programs rather than university-housed programs (Pulcini, 2013). In the 1980s and 1990s, NP education moved into the university setting as master’s-level programs, although confusion arose when there were efforts to interchange the clinical nurse specialist (CNS) and NP roles. Today there are well over 330 graduate-level NP programs, and many have gone to offering only a clinical doctorate—the doctor of nursing practice (DNP)—for NP education in response to the American Association of Colleges of Nursing’s (AACN’s) recommendation that advanced practice nurses be educated at that level by 2015. In 2008, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education was finalized through the collaborative efforts of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. To clarify who is an advanced practice registered nurse, the document included the following definition (APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee, 2008): An advanced practice registered nurse (APRN) is a nurse: 1. Who has completed an accredited graduate-level education program preparing him or her for one of the four recognized APRN roles; 2. Who has passed a national certification examination that measures APRN, role and population-focused competencies, and who maintains continued competence as evidenced by recertification in the role and population through the national certification program; 3. Who has acquired advanced clinical knowledge and skills preparing him or her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant com- ponent of the education and practice focuses on direct care of individuals; 4. Whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy; 5. Who is educationally prepared to assume responsibility and account- ability for health promotion and maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and nonpharmacologic interventions; 6. Who has clinical experience of sufficient depth and breadth to reflect the intended license; and 7. Who has obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP).1 1 APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. APRN Joint Dialogue Group Report, July 7, 2008. Nurse Practitioner Education and Title Clarification 5 Clearly, NPs are one of the four roles that fall under the umbrella definition for APRN; however, using the title “APRN” does not clearly define which role and edu- cational background the professional has. Each APRN role differs from the others, and state regulatory agencies vary in requirements for licensing in each state, and in many cases, for each APRN role. ▸ The Master’s Essentials The American Association of Colleges of Nursing (AACN) prepared the Essentials for Master’s Education in Nursing (AACN, 2011). There are nine essentials that focus on outcomes and are for all master’s-level programs. In addition, direct patient care provider (APRN) education must offer three separate courses on the “3 Ps,” which are advanced pharmacology, advanced pathophysiology, and advanced physical assessment. The nine essentials are (AACN, 2011): I. Background for practice from sciences and humanities II. Organizational and systems leadership III. Quality improvement and safety IV. Translating and integrating scholarship into practice V. Informatics and healthcare technologies VI. Health policy and advocacy VII. Interprofessional collaboration for improving patient and population health outcomes VIII. Clinical prevention and population health for improving health IX. Master’s-level nursing practice Essential IX, master’s-level nursing practice, recognizes that nursing practice, at the master’s level, is broadly defined as any form of nursing intervention that in- fluences healthcare outcomes for individuals, populations, or systems. Master’s-level nursing graduates must have an advanced level of understanding of nursing and relevant sciences as well as the ability to integrate this knowledge into practice. Nursing practice interventions include both direct and indirect care components (AACN, 2011). ▸ Nurse Practitioner Core Competencies In addition to the AACN, which strives to advance the education of nurses in general, the National Organization for Nurse Practitioner Faculties (NONPF) sets the standards for nurse practitioner programs. NONPF has stated there are core competencies for nurse practitioners in all tracks and specialties. These are listed here so the NP student can review and understand how coursework reflects these competencies (NONPF, 2017). Scientific Foundation Competencies 1. Critically analyzes data and evidence for improving advanced nursing practice. 2. Integrates knowledge from the humanities and sciences within the context of nursing science. 6 Chapter 1 Historical Perspectives: The Art and Science of Nurse Practitionering 3. Translates research and other forms of knowledge to improve practice processes and outcomes. 4. Develops new practice approaches based on the integration of research, theory, and practice knowledge. Leadership Competencies 1. Assumes complex and advanced leadership roles to initiate and guide change. 2. Provides leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated healthcare teams, and policy makers) to improve health care. 3. Demonstrates leadership that uses critical and reflective thinking. 4. Advocates for improved access, quality, and cost-effective health care. 5. Advances practice through the development and implementation of innovations incorporating principles of change. 6. Communicates practice knowledge effectively both orally and in writing. 7. Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a population focus. Quality Competencies 1. Uses best available evidence to continuously improve quality of clinical practice. 2. Evaluates the relationships among access, cost, quality, and safety and their influence on health care. 3. Evaluates how organizational structure, care processes, financing, mar- keting, and policy decisions affect the quality of health care. 4. Applies skills in peer review to promote a culture of excellence. 5. Anticipates variations in practice and is proactive in implementing in- terventions to ensure quality. Practice Inquiry Competencies 1. Provides leadership in the translation of new knowledge into practice. 2. Generates knowledge from clinical practice to improve practice and patient outcomes. 3. Applies clinical investigative skills to improve health outcomes. 4. Leads practice inquiry, individually or in partnership with others. 5. Disseminates evidence from inquiry to diverse audiences using multiple modalities. 6. Analyzes clinical guidelines for individualized application into practice. Technology and Information Literacy Competencies 1. Integrates appropriate technologies for knowledge management to im- prove health care. 2. Translates technical and scientific health information appropriate for various users’ needs. a. Assesses the patient’s and caregiver’s educational needs to provide effective, personalized health care. b. Coaches the patient and caregiver for positive behavioral change. Nurse Practitioner Core Competencies 7 3. Demonstrates information literacy skills in complex decision making. 4. Contributes to the design of clinical information systems that promote safe, high-quality, and cost-effective care. 5. Uses technology systems that capture data on variables for the evaluation of nursing care. Policy Competencies 1. Demonstrates an understanding of the interdependence of policy and practice. 2. Advocates for ethical policies that promote access, equity, quality, and cost. 3. Analyzes ethical, legal, and social factors influencing policy development. 4. Contributes in the development of health policy. 5. Analyzes the implications of health policy across disciplines. 6. Evaluates the impact of globalization on healthcare policy development. 7. Advocates for policies for safe and healthy practice environments. Health Delivery System Competencies 1. Applies knowledge of organizational practices and complex systems to improve healthcare delivery. 2. Effects healthcare change using broad-based skills, including negotiating, consensus building, and partnering. 3. Minimizes risk to patients and providers at the individual and systems level. 4. Facilitates the development of healthcare systems that address the needs of culturally diverse populations, providers, and other stakeholders. 5. Evaluates the impact of healthcare delivery on patients, providers, other stakeholders, and the environment. 6. Analyzes organizational structure, functions, and resources to improve the delivery of care. 7. Collaborates in planning for transitions across the continuum of care. Ethics Competencies 1. Integrates ethical principles in decision making. 2. Evaluates the ethical consequences of decisions. 3. Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care. Independent Practice Competencies 1. Functions as a licensed independent practitioner. 2. Demonstrates the highest level of accountability for professional practice. 3. Practices independently, managing previously diagnosed and undiag- nosed patients. a. Provides the full spectrum of healthcare services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, palliative care, and end-of-life care. 8 Chapter 1 Historical Perspectives: The Art and Science of Nurse Practitionering b. Uses advanced health assessment skills to differentiate between normal, variations of normal, and abnormal findings. c. Employs screening and diagnostic strategies in the development of diagnoses. d. Prescribes medications within scope of practice. e. Manages the health or illness status of patients and families over time. 4. Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making. a. Works to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration. b. Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. c. Incorporates the patient’s cultural and spiritual preferences, values, and beliefs into health care. d. Preserves the patient’s control over decision making by negotiating a mutually acceptable plan of care. e. Develops strategies to prevent one’s own personal biases from interfering with delivery of quality care. f. Addresses cultural, spiritual, and ethnic influences that potentially create conflict among individuals, families, staff and caregivers. 5. Educates professional and lay caregivers to provide culturally and spiri- tually sensitive, appropriate care. 6. Collaborates with both professional and other caregivers to achieve optimal care outcomes. 7. Coordinates transitional care services in and across care settings. 8. Participates in the development, use, and evaluation of professional standards and evidence-based care.2 The comprehensive components of the competencies that must be met for role development are necessary and useful for developing curricula and for evaluating the NP student during the educational training period, as well as containing standards to which the practicing NP can be held accountable. ▸ Doctor of Nursing Program (DNP)