1. Chapter 39 The Advanced Practice Nurse in the Community

2.  Briefly discuss the historical development of the roles of the advanced public health nurse and the nurse practitioner.  Describe the educational requirements for population-focused advanced practice nurses.  Discuss certification/credentialing mechanisms in nursing as they relate to the role of the advanced practice nurse. Objectives 2 Copyright © 2016 by Elsevier Inc.

3.  Compare and contrast the various role functions of population-focused advanced practice nurses.  Explore current issues and concerns related to practice.  Identify five stressors that may affect nurses in expanded roles. Objectives (Cont.) 3 Copyright © 2016 by Elsevier Inc.

4. Mike and Lexi are part of a coalition of advanced public health nurses (APHNs) that serve an interstate region. But Mike, Lexi, and the rest of their team members all have responsibilities that vary greatly from one another. APHNs have advanced degrees. Given what you have learned so far in this course, what kinds of roles might you imagine an APHN might take on? Issues in Public Health Nursing: Advanced Public Health Practice 4 Copyright © 2016 by Elsevier Inc.

5.  Start by examining the various titles a public health nurse with an advanced degree might go by:  Advanced public health nurse (APHN)  Public health clinical nurse specialist (CNS)  Nurse practitioner (NP)  Clinical nurse leader (CNL) Advanced Public Health Nurse (APHN) Titles and Roles 5 Copyright © 2016 by Elsevier Inc.

6.  Advanced public health nurse (APHN)  Nurse with an advanced degree who takes leadership roles in applying nursing process and public health sciences to achieve specific health outcomes for the community  Public health clinical nurse specialist (CNS)  Nurse with advanced degree who provides both direct patient care and expert consultation to nursing staffs; implements improvements in health care delivery systems Definitions 6 Copyright © 2016 by Elsevier Inc.

7.  Nurse practitioner (NP)  Advanced-degree nurse who, autonomously and in collaboration with health care professionals and other individuals, provides a range of primary, acute, and specialty health care services to individuals or families  Clinical nurse leader (CNL)  Master’s prepared generalist who functions at the micro-system level and assumes accountability for health care outcomes for a specific group of clients within a unit or area Definitions (Cont.) 7 Copyright © 2016 by Elsevier Inc.

8.  Shift from institution-based health care to population-focused health care  CNS role began in early 1960s  NP movement began in 1965 at the University of Colorado  Physician assistant (PA) role initiated in 1965 at Duke University  Extending the Scope of Nursing Practice (1971)  Nurse Training Act of 1971 Historical Perspective 8 Copyright © 2016 by Elsevier Inc.

9.  Quad Council of Public Health Nursing Organizations (2003)  Developed national public health competencies specific for public health nursing (PHN) practice (2003) based on the Core Competencies for Public Health Professionals (2001)  Updated in 2011  Scope and Standards for Public Health Nursing Practice (American Nurses Association [ANA], 2013) Competencies 9 Copyright © 2016 by Elsevier Inc.

10.  Minimum education: a master’s degree  Synthesis of current knowledge and research in the following areas:  Nursing  Public health  Other scientific disciplines APHN Educational Preparation 10 Copyright © 2016 by Elsevier Inc.

11.  Association of Community Health Nursing Educators’ (ACHNE’s) five role characteristics of APHNs  Population-level health care focus  Ecologic view  Responsibility for health outcomes for populations  Partnership/collaboration using an interprofessional approach  Leadership in practice  Practicum experience must—  Take place at the population level  Be grounded in an ecologic perspective  Include measurement of outcomes Educational Preparation 11 Copyright © 2016 by Elsevier Inc.

12.  Role characteristics of NPs (master’s)  Assessing and diagnosing  Conducting physical examinations, ordering laboratory and other diagnostic tests  Developing and implementing treatment plans for some acute and chronic illnesses  Prescribing medications  Monitoring client status  Educating and counseling clients  Consulting with, collaborating with, and referring to other providers Educational Preparation (Cont.) 12 Copyright © 2016 by Elsevier Inc.

13.  Educational essentials for DNPs (doctorate of nursing practice )  Knowledge with a scientific underpinning  Organizational and systems leadership  Clinical scholarship  Information systems  Policy  Collaboration  Prevention and population health  Advanced nursing practice Educational Preparation (Cont.) 13 Copyright © 2016 by Elsevier Inc.

14.  American Nurses Credentialing Center (ANCC) certificate examinations for advanced practice nurses (APNs)  NP certifications renewed every 5 years AANP competency-based exams  CNS certification Added master’s degree in public health (PH) with a specialization in community/PH nursing Changed to either advanced public health nursing or public health clinical nurse specialist; however, exams no longer offered  APHN-BC (board-certified) obtained through portfolio assessment with appropriate degrees Credentialing 14 Copyright © 2016 by Elsevier Inc.

15.  Clinician  Educator  Administrator  Consultant  Researcher Advanced Practice Roles 15 Copyright © 2016 by Elsevier Inc.

16. Remember Mike and Lexi? Both work for an interstate cooperative that comes together cyclically for research purposes. The rest of the year, Mike is a clinician and administrator, whereas Lexi is a private APHN consultant.  So how do their responsibilities differ?  And if Mike is a clinician, how does that role fit into public or population-based practice? As an APHN, how is his role different from that of a nurse practitioner? Issues in Public Health Nursing: Advanced Public Health Practice 16 Copyright © 2016 by Elsevier Inc.

17.  APHN  Conduct community assessments.  Identify needs of populations at risk.  Plan, implement, and evaluate population-focused programs to achieve health goals, including health promotion and disease prevention activities.  NP  Assess, diagnose, and treat individuals and families.  Use protocols. Clinician Roles 17 Copyright © 2016 by Elsevier Inc.

18.  Increase wellness.  Maintain and promote health.  Teach the importance of good nutrition, physical exercise, stress management, and a healthy lifestyle.  Provide education about disease processes.  Includes the importance of following treatment regimens  Provide anticipatory guidance on the use of the following:  Medications  Diet  Birth control methods  Other therapeutic procedures Educator 18 Copyright © 2016 by Elsevier Inc.

19.  May be responsible for and have direct or indirect authority and supervision over the organization’s staff and patient care  Serves as a decision maker and problem solver  May also be involved in other business and management aspects, such as the following:  Supporting and managing personnel  Budgeting  Establishing quality control mechanisms  Program planning and influencing policies  Public relations  Marketing Administrator 19 Copyright © 2016 by Elsevier Inc.

20.  Lexi works as a consultant, sometimes traveling to help communities deal effectively with population-based health challenges. So what are the responsibilities of a PH consultant?  Problem solving with an individual, family, or community to improve health care delivery  Steps of the consultation process: Assessing the problem Determining the availability and feasibility of resources Proposing solutions Assisting with implementing a solution, if appropriate Consultant 20 Copyright © 2016 by Elsevier Inc.

21. We have learned that as an APHN, Mike acts as a clinician. Which of the following roles is he likely to assume most often? A. Support and manage personnel. B. Identify the needs of a population at risk. C. Teach a parent and child how to use an inhaler. D. Establish marketing strategies for his agency. Quick Recall 21 Copyright © 2016 by Elsevier Inc.

22.  APHN clinician roles include the following:  Conducting community assessments  Identifying needs of populations at risk  Planning, implementing, and evaluating population- focused programs to achieve health goals, including health promotion and disease prevention activities Get That? 22 Copyright © 2016 by Elsevier Inc.

23.  Twice yearly, both Mike and Lexi operate as part of a research forum. As APHNs, their role in research includes the following tasks:  Conducting their own investigations  Collaborating with doctorate-prepared nurses  Purpose: to answer questions related to nursing practice and primary health care Research Role 23 Copyright © 2016 by Elsevier Inc.

24.  Primary care  Independent practice  Nursing centers  Retail clinics  Faith community nursing/parish nursing  Institutional settings  Ambulatory/outpatient clinics  Emergency departments  Long-term care facilities  Industry/occupational health Arenas for Practice 24 Copyright © 2016 by Elsevier Inc.

25.  Government  U.S. Public Health Service  Armed services  Public health departments  Schools  Other arenas  Home health agencies  Correctional institutions Arenas for Practice (Cont.) 25 Copyright © 2016 by Elsevier Inc.

26.  Legal status  Prescriptive authority  Reimbursement  Rural Health Clinic Services Act  Institutional privileges  Criteria vary by hospital and state  Most require national certification  Employment and role negotiation  Portfolios of credentials and samples of professional accomplishments Issues and Concerns 26 Copyright © 2016 by Elsevier Inc.

27.  Professional isolation  Liability  Interprofessional collaborative practice  Conflicting expectations  Professional responsibilities Role Stress 27 Copyright © 2016 by Elsevier Inc.

28.  Effects of Patient Protection and Affordable Care Act (PPACA) and Healthy People 2020  Increased need for practitioners  Need for population-focused APHNs and NPs  Prominence of interprofessional education and practice  Team-based and patient-centered care Trends in APN 28 Copyright © 2016 by Elsevier Inc.