1st APN Test Flashcards
Goldmark report
- Increase educational standards in nursing schools
- Focus student time on education (vs. staffing hospitals)
- Move educational programs to universities
- Require nurse educators to have advanced education
However, continued to have variability in nursing education
CNS Role
ANA officially recognized CNS role
Expert practitioner
Change agent
Master’s degree requirement
CNSs are first and foremost clinical experts who provide direct care to patients with complex health problems
Psychiatric CNSs continued as leaders in education and clinical settings
Frontier Nursing Service (FNS)
Founded by Mary Breckinridge in 1925
Provided care through nurse-run clinics
Documented stellar outcomes
Dr. Loretta Ford
First PNP program marked inception of modern NP role with establishment of First NP education program (pediatric) at University of Colorado as post-BSN certificate program
Lillian Wald established
Henry Street Settlement (HSS) to address needs of poor
Mayo Clinic
At St. Mary’s Hospital in Rochester, MN, Dr. William Mayo was among first physicians to recognize and train nurse anesthetists. Alice Magaw (“mother of anesthesia”) was hired and kept excellent records.
Focus of Consensus Model for APRN Regulation
focus of practice beyond role and population focus
Graduate Education 3-P’s
Physiology/pathophysiology,
Physical health assessment,
Pharmacology
Hamric’s Integrative Model
Primary Criteria graduate education, certification in the specialty, focus on clinical practice with patients
Core Competencies direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, leadership
Brooten’s Model of Transitional Care
APN transitional care was defined as “comprehensive discharge planning designed for each patient group plus APN home follow-up through a period of normally expected recovery or stabilization”
Intended to address outlier populations
Illustrates how a theory of clinical care can be studied to better understand what APNs do
Core of Implications for Practice
the core competencies of APN is the use of evidence-based practice
Leadership is not optional; it is a requirement
APNs must be a visible part of the solution to the health care system’s problems
APNs to enact advanced nursing skills rather than simply substitute for physicians
APN Scope of practice
Who, what, where, why, and how of nursing practice (ANA, 2010)
Specified in state practice acts
Specialty organizations have provided detailed and
specific descriptions for each APN role
Legal authority granted to a professional to provide and be reimbursed for health care services
Driving Forces for Common Understanding of APN Practice
Institute of Medicine (IOM)
Expansion of programs offering DNP
Affordable Care Act (ACA)
Accountable Care Organizations (ACOs)
Purpose of Conceptual Model
To articulate professional role identity and function
In practice, In research, & in education
Components of Conceptual Model
Outside Circle: Technology - Person EBP - Nursing Innovation - health Research - heath systems
Inside Circle:
caring, collaborating, reflection. professional, life long learning
LACE
APRN regulation, culminating in the LACE
Licensure,
Accreditation
Certification
Education
Regulatory framework
Novice-to-Expert Skill
Expertise does not develop simply as a matter of time
The progression from novice to advanced-beginner and then to competent level is incremental
Embodiment of a skill occurs after repeated experiences of performing the skill “as if” one actually could do it skillfully
Strategies to Facilitate Role Implementation
Join local APN groups for both peer support and networking opportunities
Identify mentors
Keep a portfolio for self-evaluation and seek feedback
Request reasonable time frames for initial patient visits, because novices take longer than experienced practitioners
Reassess demands to guard against feeling overwhelmed
Barriers in the Work Setting
Pressure to manage large numbers of patients
Resistance from staff nurses
Lack of understanding of the NP role
New billing and coding guidelines
HIPAA regulations
Monitoring for fraud and abuse
Holism
Involves a deep understanding of each patient as a complex and unique person
Recognizes the multiple dimensions of each person: physiological, social, emotional, cognitive, and spiritual
Direct Clinical Practice
Direct care is the central competency of advanced practice nursing
Six Characteristics of APN’s Direct Clinical Care
- Use of a holistic perspective
- Formation of therapeutic partnerships with patients
- Expert clinical thinking performance
- Use of reflective practice
- Use of evidence as a guide to practice
- Use of diverse approaches to health and illness management
Clinical Prevention
Counseling regarding personal health practices that can protect a person from disease or promote screening for the presence of disease
Immunization to prevent specific diseases
Chemoprevention (e.g., aspirin for prevention of cardiovascular events)
APN function aimed at early detection or prevention of problems related to treatments, disease progression, self-care deficits, or environment
APN Indirect Care Activities
Consultataion Discharge planning Care Coordination Communication with ins Guidance of bedside rn's Unit rounds Research Care initiatives
Collaboration
Competency is fundamental to successful APN practice and a critical component of collaboration
Collaboration affects patient care, including cost and quality of care
Clinical and interpersonal expertise is an underlying foundation for collaboration
Collaboration is not
Parallel communication One-sided compromise Parallel functioning Information exchange Coordination Consultation Co-management Referral
Transformational Leadership
Can lead to changes in values, attitudes, perceptions, and/or behaviors on part of leader and follower
Lays groundwork for further positive change and improvement in outcomes
Interaction in ways that inspire higher levels of motivation and morality among participants
Situational Leadership
Interaction between individual’s leadership style and features of environment or situation
Leaders and followers assume interchangeable roles
APNs find themselves in both roles
Attributes of Effective APN Leaders
Vision Timing Self-confidence and risk taking Expert communication and relationship building Boundary management Respect for cultural diversity Global awareness Balance in personal and professional life
Failure to Mentor: Leaving Other Nurses Behind
Most distressing form and most common
Advancing nurses forget roots and leave novice nurses behind or undermine their advancement
Mentoring, apprenticing, “giving a leg up” not as common in nursing as in other professions
Role of APN leaders to create more empowering and humane work environment
Evidence-based practice (EBP
Approach for clinical decision making and core competency for APN
Evidence-based practice (EBP) is conscientious, explicit, and judicious use of current best research-based evidence when making decisions about care of individual patients (Sackett et al., 1996)
Step Process of EBP
- Formulation of a clinical question
- Identification and retrieval of pertinent research findings based on literature review
- Extraction and critical appraisal of data from pertinent studies
- Clinical decision making based on results of this process
Quality Improvement (QI)
Systematic activity that is guided by outcome data in order to achieve rapid improvements in health care delivery in a specific setting(Arndt & Nestch, 2012; Glasziou, Ogrinc, & Goodman, 2010)
Designed to improve specific outcomes within local facility, clinic, and community
Common Goal of Research, EBP, and QI
Improvement of patient care
Randomized Controlled Trial (RCT)
Gold standard research design for generating evidence
First large-scale controlled trial compared streptomycin to standard care at time (bed rest)
Critical Elements of RCT
Manipulation of experimental intervention
Comparison of experimental intervention to control or comparison group
Random assignment of subjects to intervention or control group
Random Allocation
Most effective technique for spreading potentially confounding factors among treatment and control groups (Hill, 1937)
Steps of Evidence-Based Process
- Formulate a measurable clinical question
- Search the literature for relevant studies
- Critically appraise and extract evidence
- Implement useful findings in clinical decision making
PICO Model
PICO model aids nurses in formulating clinically relevant and measurable questions
PICO stands for
P - Patient population? Who is the patient population?
I - Intervention. What is the potential intervention or area of interest?
C - Comparison. Is there a comparison intervention or control group?
O - Outcome. What is the desired outcome?
National Guideline Clearinghouse
Administered by U.S. Agency for Healthcare Research and Quality (AHRQ)
Houses more than 3000 clinical practice guidelines formulated within past 5 years
Evidence Pyramid
Base of pyramid:
In vivo, in vitro models
Second rung from base:
Case studies or series
Higher rungs:
RCTs, non-randomized comparison cohort trials, and cohort or case control studies
Pyramid Illustrating
MA Systematic reviews Randomized controlled trials Non Randomized cohort Cohort case control study Case studies In vivo
Systematic Review and Meta-Analysis
Combine the results of multiple studies to determine the effect created by a specific intervention
Systematic review
Uses a structured methodology to comprehensively seek out, select, appraise, and analyze studies based on measurable clinical questions(Engberg, 2008)
Meta-analysis
Pools and analyzes results from more than one study to determine the direction and magnitude of an intervention’s effect (p-value)(Engberg, 2008)
Institute of Medicine (IOM) Definition of Primary Care
The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community
NP Core Competencies
Independent Practice
Scientific Foundation
Practice Inquiry
Technology and Information Literacy
Policy
Health Delivery System
Patient-Centered Medical Home (PCMH)
A personal clinician, coordinated care, and a long-term healing relationship
A relationship with a primary care clinician who leads a team that takes collective responsibility for patient care,
Providing for the patient’s health care needs and arranging for appropriate care with other qualified clinicians
VA System
The U.S. Department of Veterans Affairs employs over 4800 NPs, the largest employer of NPs in the country.
VA Ruling on APRN Practice: A Breakthrough for Veterans Health Care 12/13/16
Aging Populations and Primary Care
Moving to 20% of population
NPs central to addressing needs of this population
77% have two or more chronic illnesses
Care Transitions and Primary Care
High readmission rates
High cost of readmission rates
NP directed transitional care is associated with fewer first re-hospitalizations or deaths
Outcome Studies Related to Acute Care Nurse Practitioner Practice
Decreased costs,
Shorter hospital LOS
Decreased use of labs,
lower rates of UTIs and skin breakdown,
Time savings for house physicians, similar care outcomes compared with physician practices, patient/family satisfaction.
Reimbursement for ACNPs
Five major types of payers: Medicare Medicaid Indemnity-type insurance Managed care organizations (MCOs)
