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Shaping advanced nursing practice in the new millennium
Abstract
To provide a review of converging themes and trends that are shaping advanced practice nursing roles in oncology nursing.
Review and research articles, text-books, and organization documents.
The current managed care environment provides many opportunities and challenges for oncology advanced practice nurses. Advanced practice nurses have both clinical and organization competencies that enable them to mediate the clinical needs of patients and organization goals within the health care system.
Advanced practice nurses can help shape their roles and practice by active participation in the development of systems to support access to clinical and financial information for effective decision making, collaboration among disciplines, and incorporating evidence-based care in their clinical practices.
... NPs have competencies that are relevant to the challenges facing health care today (Spross & Heaney, 2000). The NP role has been seen as a way to address service gaps, physician workload, lack of continuity of care, and less-than-optimal care interventions (Andregárd & Jangland, 2015;Kilpatrick et al., 2010). ...
... The purpose of this study was to explore and describe the characteristics of the NP role in cancer care and to identify the unique value of NP-provided care. Another goal of this study was to provide helpful evidence for organizational leaders in support of effective implementation of the NP role because patient care outcomes are affected by the way in which clinical care is organized and structured (Spross & Heaney, 2000). Study participants were asked about the functions of the NP role, the ways in which NPs added value to patient care, the ways in which the NP role responded to contemporary demands in healthcare delivery, and the organizational and teambased expectations of the NP role. ...
... The nurses in this study had a strong sense of their contributions to patient care and organizational effectiveness. Although the scopes of practice of NPs and physicians can overlap Lowe et al., 2012), NPs are capable of not only taking on the clinical tasks that are offloaded by their medical colleagues, but also remaining nursingoriented and using the therapeutic benefit of nursing to "facilitate efficient and high-quality care for patients" (Hopwood, 2006, p. v), emphasizing values of holism, collaboration, coordinated care, advocacy, egalitarian partnerships with patients and families, and diverse interpersonal, counseling, and technical skills (Bakker et al., 2013;Bryant-Lukosius et al., 2007;Spross & Heaney, 2000). This positions NPs to add considerable value to patient care in response to the changing context of cancer care delivery. ...
Purpose/Objectives: To explore and describe the characteristics of the nurse practitioner (NP) role in cancer care in a Canadian province, identify the ways in which NPs add value to cancer care, and suggest ways in which organizations can better support the NP role.
Research Approach: Exploratory, qualitative design.
Setting: Three cancer care facilities in a western Canadian province.
Participants: 12 NPs in cancer care, 12 physicians working with NPs, and 5 administrators responsible for implementing the role.
Methodologic Approach: Interpretive description, a qualitative method aimed at systematically exploring and analyzing a topic and applying the findings back into practice.
Findings: Each group had a different perspective on the role and its value. Physicians regarded these high-level practitioners as “help” within their own practices. Administrators tended to use NPs to manage patient workload within the traditional physician-focused system, but they could see value in NP-led innovation. The NPs themselves envisioned a nontraditional, holistic, patient-centered approach to care that challenged the interventionist focus of the medical model. Suggestions for enhancing the potential of the role were offered by all groups.
Conclusions: Lack of clarity about the NP role persists. Traditional professional hierarchies and expectations about care delivery continue to affect role implementation.
Interpretation: Nursing leaders must be proactive about NP role implementation to maximize its potential. Additional research is needed about the outcomes of the role and the process of implementation.
... The Government of Western Australia (2003) has adopted the four core concepts as defined by the National Council (2004a). Many authors identify similar core concepts for ANPs, such as expert clinical practice, clinical and professional leadership, ethical decision-making skills, consultations, use and conduct of research, collaboration, education, coaching and guidance skills (American Association of Colleges of Nursing 1996, Hickey et al. 2000, Spross & Heaney 2000. The clinical focus of the National Council core concepts is welcome as it defines the centrality of the client in the role of advanced nursing practice. ...
... Definitions of advanced practice, ANPs, core concepts and achievements of positive health outcomes all assist in identifying the relevant competencies. ANPs possess a range of competencies that are relevant to the problems and challenges inherent in today's healthcare system (Spross & Heaney 2000). These competencies include: expert clinical practice, clinical and professional leadership, ethical decision-making skills, consultation, education and coaching and guidance skills (American Association of Colleges of Nursing 1996, Billings & Stoeckle 1999, Hamric et al. 2000, Hickey et al. 2000, Spross & Heaney 2000. ...
... ANPs possess a range of competencies that are relevant to the problems and challenges inherent in today's healthcare system (Spross & Heaney 2000). These competencies include: expert clinical practice, clinical and professional leadership, ethical decision-making skills, consultation, education and coaching and guidance skills (American Association of Colleges of Nursing 1996, Billings & Stoeckle 1999, Hamric et al. 2000, Hickey et al. 2000, Spross & Heaney 2000. Emerging roles may require additional competencies as differences amongst ANPs roles arise from the nature, depth and frequency of competencies used in the practice setting (Hamric et al. 2000). ...
This paper aims to explore the critical elements of advanced nursing practice in relation to policy, education and role development in order to highlight an optimal structure for clinical practice.
The evolution of advanced nursing practice has been influenced by changes in healthcare delivery, financial constraints and consumer demand. However, there has been wide divergence and variations in the emergence of the advanced nurse practitioner role. For the successful development and implementation of the role, policy, educational and regulatory standards are required.
The paper highlights the value of a policy to guide the development of advanced nursing practice. Educational curricula need to be flexible and visionary to prepare the advanced nurse practitioner for practice. The core concepts for the advanced nursing practice role are: autonomy in clinical practice, pioneering professional and clinical leadership, expert practitioner and researcher. To achieve these core concepts the advanced nurse practitioner must develop advanced theoretical and clinical skills, meet the needs of the client, family and the community.
In a rapidly changing people-centred healthcare environment the advanced nurse practitioner can make an important contribution to healthcare delivery. The challenges ahead are many, as the advanced nurse practitioner requires policy and appropriate educational preparation to practice at advanced level. This will enable the advanced practitioner articulate the role, to provide expert client care and to quantify their contribution to health care in outcomes research.
... Ce type de prestation des soins permet aux IPA de voir certains patients de façon autonome. La recherche indique que la présence d'IPA au sein du personnel se traduit par la perception d'une plus grande continuité au niveau des soins, ce qui a une incidence positive sur la satisfaction des patients et de leur famille quant à leur expérience du système de santé (Cunningham, 2004;Knaus, Felten, Burton, Fobes et Davis, 1997;Spross et Heaney, 2000). Il est important de souligner que l'intention des IPA n'est pas de remplacer d'autres professionnels de la santé mais plutôt de combler certaines lacunes qui existent actuellement dans notre système de santé. ...
... It is contended herein that all domains are applicable to all APN positions but that the relative emphasis on domains will vary according to the nature of the particular position and specific practice setting. Some APNs will spend more time on direct patient care, some in education and others in research or other fields (Spross & Heaney 2000, Gardner et al. 2007, Chang et al. 2010). Further comparative studies will identify how, and to what extent different levels of nurses undertake activities within each domain. ...
This study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool.
Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third article from a multi-phase Australian study aimed at assigning advanced practice roles.
A postal survey was conducted of a random sample of state government employed Registered Nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach's alpha coefficient determined reliability of the overall scale and identified factors.
There were 658 responses (42% response rate). The five factors found with loadings of ≥400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach's alpha coefficient was 0·94 overall and for the factors ranged from 0·83 to 0·95.
Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.
... Given the complexity of knowledge and skills required in breast cancer prevention, APNs are challenged to maintain evidence-based practice when addressing the needs of high-risk women from both program and individualized perspectives. An oncology APN is a nurse who has graduate education with expanded clinical, theoretical, and research-based knowledge and skills that are used in the provision of care to individuals with an actual or potential diagnosis of cancer (Oncology Nursing Society, 2001;Spross & Heaney, 2000). Although the competencies of APNs are grouped into five main areas (i.e., clinical practice, education, collaboration/consultation, research, and leadership), the effective interaction, blending, and simultaneous execution of the skills, knowledge, judgment, and interpersonal attributes in highly complex practice environments are what characterize advanced nursing practice (Canadian Nurses Association, 2000;Hamric & Spross, 1989). ...
To identify support needs of women at high risk for breast cancer and enhance an evidence-based service.
Descriptive study.
A comprehensive, breast-health service for high-risk women.
97 high-risk women with a 1.66% or greater five-year risk of breast cancer, atypical hyperplasia, lobular carcinoma in situ, or positive genetic screen.
A self-assessment questionnaire completed previsit and a satisfaction survey completed postvisit.
Women's perceived informational, emotional, and decisional support needs, current self-care practices, and satisfaction with the service provided.
Women under age 50 (n = 54) wanted information on breast cancer screening, risk of breast cancer, lifestyle options to lower risk, and hormone replacement therapy; older women (n = 43) wanted information on risk of breast cancer, lifestyle options, breast cancer screening, and chemoprevention. More than 75% of all women wanted information to help them make decisions on breast cancer prevention options, benefits, and risks. The satisfaction survey (N = 61) revealed that most women's needs were met.
Support needs were consistent with the literature that focused primarily on younger women seeking genetic counseling. Proactive planning assisted with addressing the needs of these women.
A previsit questionnaire facilitates individualized proactive planning before the visit. However, further assessment of self-care practices and emotional needs is required. Interventions should evaluate outcomes, such as accurate risk perception, lifestyle changes, screening follow-through, and decision quality. Advanced practice nurses require specialized skills, including evidence-based risk communication, behavior modification, and decision support.
... This style of care enables an APN to see some oncology patients independently. Research shows that with APNs on staff, there is a sense of enhanced continuity of care, thereby increasing patient and family satisfaction with their health care experience (Cunningham, 2004; Knaus, Felten, Burton, Fobes, & Davis 1997; Spross & Heaney, 2000). It is important to highlight that APNs are not intended to replace any health care professional but, instead, serve to address gaps that exist in our health care system. ...
I feel extremely honoured to have been asked to present at the 2004 CANO conference on a topic that is near and dear to my heart, “Are advanced practice nurses (APNs) here to stay? The APN in the oncology setting.” Oncology nursing is one of my passions. I am convinced that in life, if you want something, you have to believe in it with passion, and it is my consuming passion for nursing and advanced nursing practice that has brought me here today to speak to you, my colleagues. I challenge each of us to find our passion in nursing. It does not have to be in advanced nursing practice, but I believe we have a responsibility to support one another in our often complex pursuits.
Purpose:
The purpose of this study was to add to what is known about patient satisfaction with nurse practitioner (NP) care, from the perspective of breast cancer patients who were followed by an NP.
Methods and design:
This study utilized Interpretive Description, a qualitative method aimed at making sense of the experiential aspects of health care and developing practical knowledge for improved care. Nine patients receiving NP-led care in an outpatient breast cancer clinic were interviewed about their perspectives on and experiences with NP-led care. Interview transcripts were thematically analyzed.
Findings:
The NP role has long been regarded as a way of addressing many contemporary health system problems, although there continue to be barriers to the effective utilization of the role, including public and patient misunderstandings. This study revealed that, despite persistent traditional role understandings about health professionals, the patient participants appreciated the benefits of NP care and were highly satisfied with both the physical care and holistic support they received during the course of their treatment.
Conclusions and clinical relevance:
Today's healthcare system is characterized by accessibility issues, unmet patient need, workforce issues, and funding pressures. This research supports and enriches what is known about the benefits and usefulness of NP-provided care from the viewpoint of those receiving the care. The findings offer guidance to NPs in the clinical setting regarding patient needs and optimal care strategies.
The physician beginning practice in an outpatient breast oncology setting may be bewildered initially by the number of non-physician health professionals, their designations, and their roles. This chapter begins with a brief overview of educational levels and scope of clinical practice for the medical assistant (MA), registered nurse (RN), nurse practitioner (NP), and physician assistant (PA) in an outpatient breast oncology setting. This chapter then focuses on the role of the specialist breast nurse and reviews ways by which this advanced practice oncology nurse can facilitate patient cancer care and enhance a breast surgeon's practice.
Aim: The purpose of this study was to prepare scales to assess the difficulties, coping, and adaptation experienced by nurses involved with cancer care in order to extract the constructing factors of each scale and to investigate the correlations between the scales and sociodemographic-related factors.
Methods: The subjects were 155 full-time staff nurses who provided care to cancer patients undergoing chemotherapy or radiotherapy at outpatient, day-care or short-stay wards in 14 oncology and general hospitals throughout Japan. The participants completed a questionnaire that consisted of questions relating to demographic information and three item lists: the difficulties, coping, and adaptation associated with providing care to patients undergoing cancer therapy.
Results: Based on the results of the factor analysis for each scale, four factors of the Difficulties scale, three factors of the Coping scale, and five factors of the Adaptation scale were identified. A stepwise multiple regression analysis was performed by using the Adaptation scale score as a criterion variable and the Difficulties and Coping scale scores, and demographic factors as independent variables. The standardized partial regression coefficient was significant for coping and age in descending order.
Conclusion: The results of this study suggested that coping plays a significant role as a predictor of adaptation.
This paper will describe the implementation of inter-professional work based education (IPE) in one postgraduate Advanced Practitioner programme in the UK. The concept of Advanced Practice has developed as a response of a number of drivers including change in junior doctor training; government policy and increasing demands on the central government funded UK health service (the NHS). The programme was commissioned by the then greater Manchester Strategic Health Authority (now NHS North West) to meet service needs. The educational philosophy underpinning the MSc Advanced Practice (health and social care) provided by the University of Salford is IPE linked to work based learning. The process of work based learning (WBL) and inter-professional learning underpinning the programme will be discussed in relation to feedback from university staff, Advanced Practitioner (AP) students and employer feedback taken from programme and module evaluations. We argue that IPE at this level facilitates a greater understanding of the connectivity between professionals working in the health care system in the UK; a better understanding of the skills and knowledge base of colleagues; more inter-professional working and appropriate referrals in the work place. This has raised the profile of Advanced Practice (AP) in the region and ultimately resulted in better patient care with more effective and efficient use of resources (Acton Shapiro, 2006, 2008).
To analyze and clarify the conceptual basis of advanced practice nursing to determine the state of the knowledge from the perspective of four overarching principles derived from the philosophy of science: epistemological, pragmatic, linguistic, and logical.
Written discourse regarding advanced practice nursing from refereed journals published between 2000 and 2007.
Conceptualization of a core definition of advanced practice nursing will enhance external legitimacy and recognition; understanding advanced practice nurse (APN) roles, sub-roles, and competencies will enhance internal cohesion. The outcome of this concept analysis is a greater understanding of the conceptual basis of advanced practice nursing and a current best estimate of the probable truth surrounding advanced practice nursing.
A greater understanding of the conceptual basis of advanced practice nursing will help to gain clarity, internal cohesion, external legitimacy, and acceptance of APN roles by society and other healthcare professions.
To describe the importance of standardized nursing vocabularies as a foundation for quality in health care decision-making.
Literature, online sources, and committee documents.
Several standardized vocabularies are recognized by the American Nurses Association Committee for Nursing Practice Information Infrastructure. Vendors also have integrated the vocabularies into their information systems. Future efforts include developing an international nursing reference terminology.
Oncology nurses face quality of care issues that impact decision-making at the point of care. To describe their practice, oncology nurses must strive to use nursing data that are standardized, documented, and made visible by inclusion in computer-based systems.
Graduate nursing education is evolving in response to multiple societal influences affecting higher education. Nurse anesthesia education has also been affected by these forces. This article describes the planning, implementation, and evaluation of a new graduate track in nurse anesthesia made possible by an academic partnership, and the positive impact that a federally funded grant had on the venture. The excellent academic outcomes, the changes in diversity of the student body, the innovative curriculum, and lessons learned from the project are described.
A literature review for studies of job satisfaction among nurse practitioners (NPs) suggests that the true determinants of job satisfaction have not been discovered. The purpose of this study was to determine job satisfaction among adult health NPs (ANPs) practicing in Arizona.
The Misener nurse practitioner job satisfaction scale was mailed to 329 Arizona ANPs who were certified by the Arizona State Board of Nursing (47% response rate).
The mean overall satisfaction score was 4.69 out of a possible score of 6.0 for very satisfied. Differences in employer type, gender, annual income, membership in professional nursing organization, or full-time versus part-time employment status did not result in significantly different scores on the job satisfaction scale in this group.
A deep and sustained nursing shortage, the exodus of experienced nurses from the profession, and a projected shortage of primary care providers have generated interest among professional groups, private and government healthcare commissions, and the healthcare industry in determining what factors may influence an individual to choose and remain active in nursing practice. Researchers, educators, employers, and the healthcare industry must look beyond well-worn assumptions about job satisfaction to explore what the individual NP finds satisfying about his or her role.
To determine the safety, efficacy, and cost savings of early hospital discharge of very-low-birth-weight infants (less than or equal to 1500 g), we randomly assigned infants to one of two groups. Infants in the control group (n = 40) were discharged according to routine nursery criteria, which included a weight of about 2200 g. Those in the early-discharge group (n = 39) were discharged before they reached this weight if they met a standard set of conditions. For families of infants in the early-discharge group, instruction, counseling, home visits, and daily on-call availability of a hospital-based nurse specialist for 18 months were provided. Infants in the early-discharge group were discharged a mean of 11 days earlier, weighed 200 g less, and were two weeks younger at discharge than control infants. The mean hospital charge for the early-discharge group was 27 percent less than that for the control group (64,940; P less than 0.01), and the mean physician's charge was 22 percent less (7,649; P less than 0.01). The mean cost of the home follow-up care in the early-discharge group was 18,560 for each infant. The two groups did not differ in the numbers of rehospitalizations and acute care visits, or in measures of physical and mental growth. We conclude that early discharge of very-low-birth-weight infants, with follow-up care in the home by a nurse specialist, is safe and cost effective.
To study the effects of a comprehensive discharge planning protocol, designed specifically for the elderly and implemented by nurse specialists, on patient and caregiver outcomes and cost of care.
Randomized clinical trial.
Hospital of the University of Pennsylvania.
276 patients and 125 caregivers. Patients were 70 years and older and were placed in selected medical and surgical cardiac diagnostic-related groups.
Group differences in patient outcomes (length of initial hospital stay, length of time between initial hospital discharge and readmission, and rehospitalization rates) and charges for care (charges for initial hospitalization, rehospitalizations, health services after discharge, and nurse specialist services) were measured 2, 6, and 12 weeks after discharge.
From the initial hospital discharge to 6 weeks after discharge, patients in the medical intervention group had fewer readmissions, fewer total days rehospitalized, lower readmission charges, and lower charges for health care services after discharge. No differences in these outcomes were found between the surgical intervention and control groups during this period.
Study findings support the need for comprehensive discharge planning designed for the elderly and implemented by nurse specialists to improve their outcomes after hospital discharge and to achieve cost savings. The findings also suggest that this intervention had its greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge.
This article is a retrospective descriptive analysis of the first 1,000 births conducted by the Nurse-Midwifery Group of Fresno County, California, over the period from 1980 to 1985. The multiethnic patient population was of mixed obstetric risk. Nurse-midwifery care was offered within the context of a comprehensive maternity care program in close collaboration with a perinatal health care team. Patient care outcomes were quite favorable when compared with county and state statistics. A perinatal mortality rate of 7.01,000 was observed. The incidence of low birth weight infants (5.7%) and the cesarean section rate (7.7%) were also lower than county and state statistics. These data add to the growing body of literature that suggests that nurse-midwifery care, within the structure of collaborative practice, can be effective and advantageous. The nurse-midwifery service made a contribution to access to perinatal care for the residents of this community.
Does there need to be one predominant advanced nursing role that merges the Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS)? This paper examines the history of these two specialties within medical surgical arenas, their role differences along with legal and educational forces that influence this reoccurring question in an attempt to put this question into perspective.
This is the seventh in a series of eight articles analysing the gap between research and practiceSeries editors: Andrew Haines and Anna DonaldDespite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews.
Summary points
Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings
Passive dissemination of information is generally ineffective
It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice
Further research on the relative effectiveness and efficiency of different strategies is required
Identification and inclusion of systematicreviews
We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination. The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group4 had been published during this time. In addition, we searched the Database of Abstracts of Research Effectiveness (DARE) (http://www.york.ac.uk/inst/crd) but did not identify any other review meeting the inclusion criteria.
We searched for any review …
This exploratory study examined whether outcomes of care for HIV-infected patients are related to whether the patient's primary provider is a physician (MD) or a nurse practitioner (NP). Functional status, symptom occurrence, self management, health service use and patients' assessment of their care were evaluated for 87 HIV-infected patients in a teaching hospital outpatient setting. NP patients were three times as likely to report their health status as only fair or poor (odds-ratio=3.06, p=.028), and reported significantly more unpleasant symptoms over a four-week period. Despite being in poorer health than patients cared for by physicians, NP patients functioned at comparable levels and used no more health care services than MD patients. NP patients reported 45 percent fewer problems with their care (p=0.003). Findings suggest that more extensive use of nurse practitioners could safely enhance access to care for persons with HIV-related illnesses.
The major findings of the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT), a multimillion dollar, multisite investigation of the process of dying in American hospitals, were extremely disappointing to the medical community. The major conclusion of this intervention study was that increased efforts to improve communication about patients' preferences for end-of-life care to physicians did not have a significant impact on the care that is provided in hospitals. In a commissioned series of papers to examine the conclusions of the study, numerous factors were identified as the possible reasons for the SUPPORT findings. Among the factors was the role of nurses in communicating patients' preferences to physicians. Nurses, however, were not participants in the design and conduct of this study nor were they among those who were respondents to the conclusions of SUPPORT. In this manuscript, an analysis of the report of the SUPPORT study itself and the commentaries commissioned by its funding agency are reported. Numerous issues about the scientific rigor of SUPPORT, the perceived roles of nurses in end-of-life decision making, and the need for interdisciplinary collaboration in health care and health care research are presented in an effort to ensure that nurses' contributions to the quality of patient care are recognized, acknowledged, and valued in the future.
Typescript. Thesis (M.S.N.)--Duke University, 1994. Vita. Includes bibliographical references.
Because cost containment is a priority in our rapidly changing American health care system, the prestigious Pew Health Professions Commission (1995) has predicted a greater role for nurse practitioners (NPs) in the delivery of primary care. Factors favoring a broadened scope of NP responsibility for primary care include: (a) the pressing need to contain the nation's ever-escalating health care costs, (b) the present window of opportunity for advanced nursing practice, and (c) the need to use fewer resources more effectively. Because ours is a market-driven health care system with a growing surplus of physicians, NPs increasingly find themselves in direct competition with physcians for the same primary care jobs. Hence, market-driven (rather than identical) pricing of services is necessary if NPs are to compete successfully with medically trained providers of primary care. The brain has two functions: One is to be right and the other is to survive and sometimes we give up the latter. (Old Chinese proverb)
On June 11, 1996, Governor George V. Voinovich signed Sub SB 154, The Advanced Practice Nursing Bill, into law. This event followed six legislative attempts in the past decade to grant legal authority for Advanced Practice Nurses (APNs) in Ohio (Pearson, 1996). Title protection, scope of practice, collaboration/supervision arrangements with physicians, Board of Nursing regulation and education/certification requirements for nurse practitioners (NPs), nurse midwives (NMs), nurse anesthetists (NAs), and clinical nurse specialists (CNSs) have been tenaciously negotiated by nurses, physicians, hospitals, pharmacists, insurers and legislators. (Stir & Savino, 1996). However, the celebration of this monumental achievement may be overshadowed by an even greater controversy within the nursing profession -- to merge or not to merge the roles of the NP and the CNS. That is the question! The position taken in this paper is that we must merge the roles to create an Advanced Practice Nurse (APN) role.
The purpose of this paper is to contribute to the debate on whether or not the roles of the clinical nurse specialist (CNS) and nurse practitioner (NP) should be blended. In this paper I argue that the two roles should not be blended in masters degree programs for two reasons. First, societal needs for the advancement of nursing practice through the generation and utilization of nursing science and the provision of expert nursing care for highly complex problems have never been greater. Secondly, the two roles should not be blended because the competencies required for the two roles are more different than alike; hence the development of important competencies for one or both roles is lost in time-limited masters programs. Each of these reasons are discussed below.
Included in this study were all patients with symptoms of respiratory tract infection and female patients with symptoms of urinary tract and vaginal infections who sought care from a hospital-based outpatient department walk-in unit which was operated in two different modes: experimental (the "nurse-protocol mode")-in which a nurse practitioner guided by a protocol initially evaluated all such patients and independently managed many patients- and traditional-in which only physicians managed patients. Safety, effectiveness, efficiency, and cost of care rendered for these tracer conditions in the two modes were compared. No serious illnesses were overlooked by practitioners in either mode. Eighty-six percent of patients in the nurse-protocol mode and 73 percent of patients in the traditional mode reported good symptom relief. Patients reported equivalent satisfaction with care. The time physicians spent managing patients with these complaints was reduced by 91 percent from 15.5 minutes to 1.4 minutes per patient. Personnel costs were equivalent in the two modes. Costs of laboratory tests and medications ordered were 27 percent less in the nurse-protocol mode. The study indicated that care in the nurse-protocol mode was of equivalent quality, led to equivalent patient satisfaction, allowed a substantial reduction in physician time, and reduced overall costs of care.
The use of a Fast Track system in the emergency department is becoming increasingly popular in order to provide fast and efficient service to patients with minor emergencies. In this paper we describe the one-year results of our system staffed by nurse practitioners. During the first year of operation, a total of 4468 patients were seen in Fast Track. Approximately 28% of patients are triaged to Fast Track during its hours of operation. The average patient seen in Fast Track was ready for discharge 94.4 minutes after presentation. Fewer than 1% of patients required admission to the hospital. Overall, patients and medical staff were highly satisfied with the Fast Track system. Our experience demonstrates that nurse practitioners can effectively and efficiently staff a Fast Track in an academic emergency department.
This article is a retrospective descriptive analysis of the first 1,000 births conducted by the Nurse-Midwifery Group of Fresno County, California, over the period from 1980 to 1985. The multiethnic patient population was of mixed obstetric risk. Nurse-midwifery care was offered within the context of a comprehensive maternity care program in close collaboration with a perinatal health care team. Patient care outcomes were quite favorable when compared with county and state statistics. A perinatal mortality rate of 7.0/1,000 was observed. The incidence of low birth weight infants (5.7%) and the cesarean section rate (7.7%) were also lower than county and state statistics. These data add to the growing body of literature that suggests that nurse-midwifery care, within the structure of collaborative practice, can be effective and advantageous. The nurse-midwifery service made a contribution to access to perinatal care for the residents of this community.
From July 1971, to July 1972, in a large suburban Ontario practice of two family physicians, a randomized controlled trial was conducted to assess the effects of substituting nurse practitioners for physicians in primary-care practice. Before and after the trial, the health status of patients who received conventional care from family physicians was compared with the status of those who received care mainly from nurse practitioners. Both groups of patients had a similar mortality experience, and no differences were found in in physical functional capacity, social function or emotional function. The quality of care rendered to the two groups seemed similar, as assessed by a quantitative "indicator-condition" approach. Satisfaction was high among both patients and professional personnel. Although cost effective from society's point of view, the new method of primary care was not financially profitable to doctors because of current restrictions on reimbursement for the nurse-practitioner services.
We prospectively studied treatment and outcome of 5030 patients in intensive care units at 13 tertiary care hospitals. We stratified each hospital's patients by individual risk of death using diagnosis, indication for treatment, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. We then compared actual and predicted death rates using group results as the standard. One hospital had significantly better results with 69 predicted but 41 observed deaths (p < 0.0001). Another hospital had significantly inferior results with 58% more deaths than expected (p < 0.0001). These differences occurred within specific diagnostic categories, for medical patients alone and for medical and surgical patients combined, and were related more to the interaction and coordination of each hospital's intensive care unit staff than to the unit's administrative structure, amount of specialized treatment used, or the hospital's teaching status. Our findings support the hypothesis that the degree of coordination of intensive care significantly influences its effectiveness.
This experimental field study compared knowledge, satisfaction and compliance in 62 nonurgent emergency room (ER) patients based on whether they were cared for by a nurse practitioner (experimental group) or a physician (control). Data were collected via structured interviews in the ER, two weeks later by phone and three months later by phone, mail and chart review. No significant differences were found between groups in overall short- and long-term compliance scores, appointment-keeping scores for the three-month study period, number of health recommendations recalled, resolution of health problem or satisfaction ratings of ER care. It was also found that: referrals were the recommendation least complied with; 60 percent of appointments were kept; frequent reasons for noncompliance were inconvenience and lack of perceived need; experimental subjects showed greater comprehension of diagnostic recommendations and therapeutic applications, while controls had better knowledge of medications; 77 percent of experimentals were completely satisfied with NP care, as compared to only 48 percent of the controls with MD care; and reasons for satisfaction centered on the quality of care, while reasons for dissatisfaction focused on unresolved problems and slow care.
Cancer is newly diagnosed in more than 1 million Americans annually, and 1 of 5 deaths in the United States -- about 1400 per day -- results from cancer1. Cancer is increasingly prevalent in the United States, yet unfortunately, the pain associated with it is frequently undertreated in both adults and children. Patients with cancer often have pain from more than one source, but in up to 90 percent of patients the pain can be controlled by relatively simple means. Nevertheless, undertreatment of cancer pain is common because of clinicians' inadequate knowledge of effective assessment and management practices, negative . . .
During this time when the walls that divide inpatient, outpatient, primary, tertiary, and community care are coming down, society should expect that the nursing profession will prepare and regulate advanced nursing practice for the good of patient care and society as a whole. To do so, schools with clinical practice graduate programs must create a consistent product; professional credentialing bodies must use consistent criteria to acknowledge advanced practice knowledge and expertise; and state boards of nursing must give legal recognition for advanced practice to these same nurses. Within this environment, advanced practice nurses will be prepared to serve society, even if their skills are applied in a variety of roles.
As new opportunities for acute care nurse practitioners (ACNP) evolve, there is increasing recognition of the need to distinguish between the knowledge base and the role functions generic to all advanced practice nurses, and the knowledge base specific to different areas of clinical specialization. This necessitates differentiating between converging core curriculum elements and merging the roles of advanced practice nurses. This article presents an educational model for the ACNP.
Seventy patients with RA were randomly allocated to either a Rheumatology Nurse Practitioner (RNP) or Consultant Rheumatologist (CR) clinic. They were seen on six occasions in 1 year. Effectiveness and safety were assessed by biochemical, clinical, psychological and functional variables; patient knowledge and satisfaction were measured by questionnaire.
At week 0 the groups were well matched clinically and demographically. By week 48 significant improvements had occurred in plasma viscosity and articular index within both groups. In patients managed by the RNP, pain, morning stiffness, psychological status, patient knowledge and satisfaction had all improved significantly (P = 0.001; P = 0.028; P = 0.0005; P<0.0001; P<0.0001 respectively), improvements not mirrored by the CR cohort.
Between group comparisons also showed significant differences by the end of the study. Compared to the CR patients, the RNP suffered from lower levels of pain (P<0.05), had acquired greater levels of knowledge (P<0.0001) and were significantly more satisfied with their care (P<0.0001).
This study was designed to assess the impact of selected medical interventions during labor upon cesarean section rates by comparing the maternal and neonatal outcomes of obstetrician- and nurse-midwife-managed low-risk private patients. All patients who delivered at Prentice Women's Hospital in Chicago, Illinois, from January 1, 1987 through December 31, 1990 were evaluated for low-risk criteria to be included in the study. During that time, the nurse-midwives delivered 573 patients and the obstetricians delivered 12,077 patients. Patients with fetal and maternal complications known to increase the cesarean section rate were eliminated from both groups. Eight percent of the nurse-midwife patients and 32% of the physician patients were eliminated, leaving 529 nurse-midwife patients and 8,266 physician patients. These patients were compared for race, parity, age, and birth weight. Information was collected from a perinatal data base and hospital computerized statistics. The rates of cesarean section, administration of oxytocin, analgesia, anesthesia, and infant outcome data were compared by chi-square analysis. Multiple logistic regression analysis was used to assess factors that predicted cesarean section. Nurse-midwife-managed patients had a significantly lower rate of cesarean section (8.5% versus 12.9%; P < .005) and operative vaginal delivery (5.3% versus 17%, P = .0001) than the physician-managed patients. Epidural anesthesia and oxytocin for induction and augmentation were used significantly more frequently in the physician-managed patients. Both interventions were associated with an increased rate of cesarean section. Fetal outcomes in the two groups were not statistically different. Women cared for by nurse-midwives had a lower cesarean section rate, fewer interventions, and equally good maternal and infant outcomes when compared with those cared for by physicians.
The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.
A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.
Many people use unconventional therapies for health problems, but the extent of this use and the costs are not known. We conducted a national survey to determine the prevalence, costs, and patterns of use of unconventional therapies, such as acupuncture and chiropractic.
We limited the therapies studied to 16 commonly used interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. We completed telephone interviews with 1539 adults (response rate, 67 percent) in a national sample of adults 18 years of age or older in 1990. We asked respondents to report any serious or bothersome medical conditions and details of their use of conventional medical services; we then inquired about their use of unconventional therapy.
One in three respondents (34 percent) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The latter group had made an average of 19 visits to such providers during the preceding year, with an average charge per visit of 13.7 billion, three quarters of which (12.8 billion spent out of pocket annually for all hospitalizations in the United States.
The frequency of use of unconventional therapy in the United States is far higher than previously reported. Medical doctors should ask about their patients' use of unconventional therapy whenever they obtain a medical history.
To determine whether a specialized, multidisciplinary twin clinic could reduce rates of very low birth weight (VLBW) and perinatal mortality. Multifetal gestations account for only 1% of all pregnancies, yet are responsible for nearly 10% of all perinatal mortality. Very low birth weight (less than 1500 g) infants are the major contributors to this increased perinatal mortality rate.
Eighty-nine twin pairs followed in the Twin Clinic since 1988 were compared with 51 contemporary twin pairs who did not attend the Twin Clinic. Patients not attending the Twin Clinic were attended in the high-risk clinic by the obstetric residents and faculty. All maternal transports were excluded. Aspects of prenatal care emphasized in the Twin Clinic that differed from the high-risk clinic included consistent evaluation of maternal symptoms and cervical status by a single certified nurse-midwife, intensive preterm birth prevention education, individualized modification of maternal activity, increased attention to nutrition, and tracking of clinic non-attenders.
There were no differences between the groups in demographic characteristics, adequacy of prenatal care, or antepartum complications. However, Twin Clinic attenders had lower rates of VLBW infants, neonatal intensive care unit admission, and perinatal mortality.
These improvements in perinatal outcome for twin gestations are attributed to intensive preterm birth prevention education, individualization of prenatal care, and frequent maternal assessment by a consistent care provider. This approach reduced the rate of very early preterm delivery and its neonatal sequelae.
To review the education of the advanced practice nurse (APN) with a focus on curriculum and issues related to the oncology specialization.
The State-of-the-Knowledge Conference on Advanced Practice in Oncology Nursing, journal articles, monographs, and authors' personal experiences.
APN education is a current issue in nursing, as well as in the specialty of oncology nursing. Current trends in the delivery of health care require reform of graduate education in nursing to better prepare APNs to shape and respond to the healthcare needs of the public along the entire cancer care continuum.
APN education remains a dynamic, ever-evolving enterprise. The Oncology Nursing Society (ONS) and the American Cancer Society (ACS) have taken a proactive stand on APN education by revising master's curriculum guidelines and supporting the conference.
APN education in oncology will be an ongoing area of exploration for both ONS and ACS, as well as for leaders in oncology nursing. Development of graduate, postgraduate, and continuing education programs at the APN level of expertise will support high-quality advanced practice in oncology nursing. The feedback mechanisms among practice, education, and research will provide educational programs that will make a difference in the care of patients with cancer.
To describe the characteristics and activities of nurse practitioners (NP) with a focus in oncology.
Descriptive.
129 NPs employed in an oncology setting who completed on NP program and were functioning in the NP role.
Subjects completed an eight-page, self-administered questionnaire comprised of fixed-choice and open-ended questions.
Demographics, employment settings, populations served, advanced practice subroles, clinical functions, practice privileges, reimbursement issues, job descriptions, performance appraisals, job satisfaction, and facilitators/barriers to role implementation.
The majority of oncology NPs (ONPs) were located in the eastern United States in university-affiliated hospitals. The most common patient population served by the respondents was adults in the medical oncology outpatient setting. More than three-quarters of the respondents worked from protocols, almost two-thirds performed procedures traditionally performed by physicians, and approximately half had prescriptive authority. Few NP respondents reported that they obtained direct reimbursement for their services from third-party payors. Physicians were cited as the most facilitative of the NP role, and administrators were cited as the most frequent barrier. The vast majority of the respondents were satisfied with their roles.
The NP role in oncology is established and expanding. The scope of practice and more detailed characterization of the role is an area for future research. Data on the effectiveness of ONPs, particularly regarding cost-effectiveness, quality of care, and patient satisfaction, are needed to maintain their viability within the healthcare system.
Reduced risk of complex response is proposed as a category of outcomes sensitive to the effects of advanced practice nursing. Processes of risk assessment and risk management are described. The goals are to identify complex responses whose occurrence is high in human and/or economic costs, to assess factors associated with these complex responses, to provide good information to support interventions that reflect the values of the discipline, and to make the effectiveness of advance practice registered nurses visible.
This article provides a very general overview of the group of diseases called cancer. The clinical practice of the nurse practitioner emphasizes health maintenance and promotion of a healthy life style. This focus can carry over into the survival phase of the cancer experience. Counseling about risk status and risk reduction are an integral part of the total approach to cancer care. These activities can be integrated into standard care delivered by the nurse practitioner.
This article evaluates the state of the science with respect to morbidity, mortality, and adverse effects as outcomes indicative of variations in organizational variables in care delivery systems.
Eighty-one research papers research examining relations among organizational structures or processes and mortality/adverse effects were reviewed, assembled from electronic and manual searches of the biomedical and health services research literature.
Most research relating mortality and other adverse outcomes to organizational variables has been conducted in acute care hospitals since 1990, with these outcome indicators linked more frequently to organizational structures than to organizational or clinical processes. There is support in some studies, but not in others, that nursing surveillance, quality of working environment, and quality of interaction with other professionals distinguish hospitals with lower mortality and complications from those with higher rates of these adverse effects. Increasing sophistication of risk adjustment methods suggests that variations in mortality and complications are influenced by patient variables more than by organizational variables. Adverse events may be a more sensitive marker of differences in organizational quality in acute care hospitals and long-term care.
Taken together, the acute care studies are not conclusive regarding the extent to which the organizational features of care delivery systems positively influence such bottom-line outcomes as mortality. As severity-adjustment methods become more refined for hospital patients, many of the small differences currently seen in mortality and complications may disappear. However, given that adverse events appear more closely related to organizational factors than in mortality, researchers need to refine and better define such events that are logically related to the coordinative organizational processes among caregivers. Finally, researchers need to go much beyond mortality, morbidity, and adverse events in evaluating the linkage between the organization of care and outcomes.
To examine the evolution of the advanced practice role in oncology nursing and the authors' educational experiences and role transitions as they progressed through a post-master's nurse practitioner (NP) certificate program.
Professional literature and personal experiences of two experienced oncology clinical nurse specialists (CNSs).
Despite historical differences between CNS and NP roles, the authors did not subtract or detract from their CNS roles but added new skills to their established roles.
Skills that define both the NP and CNS roles must be maintained to effectively meet the current healthcare needs of patients with cancer.
Many CNSs are returning to school to obtain their NP credentials. Although assimilating new skills and knowledge into an already established professional identity was a challenging undertaking, the authors viewed the experience as essential in preparing them to meet the demands of the changing healthcare environment.
Outcomes management as a patient management system has been designed to impact and improve select outcomes. Central to the development and implementation of best practice senario identified throughout outcomes management is the advanced practice nurse. SLEH has been in the forefront of development and implementation of an outcomes management program. This article describes the outcomes management position and shares the job description and performance evaluation used at this institution. The tools allow for measuring and quantifying the impact of the outcomes manager position on improving patient outcomes. The improvement of outcomes has increased the value of the advanced practice nurse and provided the institution with a solid future necessary for survival in a managed care market.
Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.
Although physician and nurse relationships have traditionally been a challenge, evolving changes in health care delivery offer the advanced practice nurse (APN) on opportunity to redefine the scope. Several issues will have an impact on this course. Initially, the condition of employment, as well as the physician's perception of the APN's role and the physician's commitment to role preservation, will be primary influences. Secondary factors include defining the role, scope of practice, and mechanisms for practice evaluation. This process will require and ongoing dialogue and selected strategies to develop and maintain physician relationships.
Managed care is a process of health-care management that integrates financing, cost-containment strategies, and business principles with the delivery of health care. Managed care's rapid transformation of specialty practices, such as oncology, is redirecting classic nursing functions toward market initiatives that value the design of care/case management systems and the implementation of multidisciplinary "patient-centered" care models. As health-care systems continue to evolve, advanced practice nurses (APNs) are redefining their roles and enhancing their skills to meet the demands of the marketplace. Advanced practice nurses are defined as registered nurses who have met advanced educational and practice requirements and are prepared at the graduate level. This paper will identify the four established APN roles: nurse practitioner (NP), nurse anesthetist, nurse midwife, and clinical nurse specialist (CNS), as well as highlight the nurse practitioner and clinical nurse specialist as the leadership APN roles within oncology practice. The adaption to managed care has identified new functions and created opportunities for these APN specialties that are being viewed both competitively by other oncology health-care providers and creatively by managed-care organizations. The integration of these emerging roles within the new advanced nursing market and their contributions to oncology care are also discussed.
The empirical and expository literatures about advanced nursing practice have lacked a broad, comprehensive, conceptual framework to organize and guide substantive work. Such a framework is needed during the development of health care policy, educational curricula, role descriptions, and research agendas for this arena of practice. The framework proposed in this article represents an integrative synthesis of previous work on advanced nursing practice. The proposed framework is based on the definition of advanced practice nursing as professional health care activities that (1) focus on clinical services rendered at the nurse-client interface, (2) use a nursing orientation, (3) have a defined but dynamic and evolving scope, and (4) are based on competencies that are acquired through graduate nursing education. Advanced practice nursing is comprised of activities in the domains of advanced clinical practice, health care systems management, and professional involvement in broad health care discourse.
Fostering open dialogue, listening, and promoting healthy lifestyles will build solid relationships between physician staff and management. Solid relationships will reduce physician burnout and ultimately, keep a safe and happy productive environment that provides quality health care delivery during ever increasing demands for workplace change.
For approximately 8 million Americans alive today, the words "cancer" and "survival" are no longer mutually exclusive. As advances are made in the early detection and treatment of cancer, the numbers of survivors who are recovering from their illnesses or living longer with cancer as a chronic disease are increasing. With this extended survival comes a new set of responsibilities and standards for follow-up care that include the following: (1) the recognition of chronic or potential problems, (2) the need for life-long surveillance, and (3) continued access to quality health care. Long-term follow-up care for cancer survivors can be a specialty unto itself. The development of clinics or programs that specialize in caring for this expanding population have a history within pediatric oncology. The challenge in the current health care market is to dedicate energy and resources to do the same within the adult oncology community. Nurse practitioners are ideal candidates to create holistic programs that focus on the special needs, both biomedical and psychosocial, of long-term cancer survivors.
Because incontinence is one of the most common problems encountered in the home care setting, home care agencies are beginning to recognize the importance of having a continence care program, and the need for advance practice nurses (APNs) to assume roles as continence care nurses (CCNs) is increasing. Through a comprehensive continence care program, incontinence is curable and easy to treat. This article describes the role of the APN as a CCN, and provides a description of the assessment and therapeutic management of the various types of urinary incontinence, focusing on the elderly patient in the home care setting.
Regulatory and market forces are dramatically affecting the practice prospects for advanced practice nurses (APNs). Examples include the designation of APNs as primary care providers by for-profit capitated systems, the elimination of "geographic" practice boundaries by the advent of telepractice, and the revision of governmental reimbursement provisions for entire categories of APNs. Educational, political, and economic challenges necessitate an increased APN leadership role in national and state policy reform efforts.