1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 22 Advanced Practice Nursing: The Latest Issues and Trends

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Role Definition Advanced practice registered nurses (APRNs) –Nurse Practitioner (NP) –Clinical Nurse Specialist (CNS) –Certified Nurse Midwife (CNM) –Certified Registered Nurse Anesthetist (CRNA)

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nurse Practitioners RNs with advanced graduate education, clinical training Provision of wide range of health care services –Diagnosis and management of common and complex medical conditions –Individuals of all ages

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Specialist RN with graduate degree in nursing as CNS Expert clinician in specialized practice area Working in variety of settings Provision of direct patient care Provision of expert consultation Implementation of improvement in health care delivery systems Integration of nursing practice with medical diagnosis and treatment of disease, injury, and disability

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Certified Nurse Midwife Primary care for women across the lifespan –Special emphasis on pregnancy, childbirth, and gynecologic and reproductive health –Also inclusion of male partners for sexually transmitted infections –Care of the normal newborn during the first 28 days of life –Focus on special needs of women Graduation from nurse midwifery program; successful completion of national certification examination

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A master’s degree is required to become a clinical nurse specialist.

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. To be a clinical nurse specialist, the nurse must have graduate preparation, a master’s or doctorate degree, in nursing.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Certified Registered Nurse Anesthetist Licensed professional nurse; provision of same anesthesia services as anesthesiologist Administration of anesthesia in 4 general categories –Preanesthetic preparation and evaluation –Anesthesia induction, maintenance, emergence –Postanesthesia care –Perianesthetic and clinical support function

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Background of APRNs Continuing high numbers of errors requiring nurses with advanced degrees to remain in practice Nursing as a key profession to lead way to significant change to the health care system Lack of enough doctoral nurses impacting achievement of patient-centered, cost-effective, and safe health care system Reasons for not pursuing advanced degrees –Salary discrepancies –Length of time for degree –Costs for returning to school

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Background of APRNs (cont.) Need for research by PhD-prepared nurses, clinically active professionals with a background in policy, leadership, and organizational behavior Landmark reports: AHA Commission on Workforce for Hospitals and Health Systems; Joint Commission on Accreditation of Healthcare Organizations; Robert Wood Johnson Foundation AACN task forces

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Doctor of Nursing Practice (DNP) Research-focused Practice-focused –Nursing practice (direct care, care management, nursing and health care organization administration, health policy development and implementation) –Practice doctorate: highest level of nursing practice

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Doctor of Nursing Practice (cont.) First program at Case Western Reserve University (1979) as doctor of nursing (ND); recently converted to doctor of nursing practice (DNP) Practice doctorate (DNP, ND) vs. research doctorate (PhD, DNS/DNSc) Research doctorate: scientific content and research methodology; original research project; dissertation Practice doctorate: innovative, evidence-based practice reflecting credible research Both complementary, alternative approaches

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Doctor of Nursing Practice (cont.) Position statement on practice doctorate in nursing (DNP as entry level for APRN) The Essentials of Doctoral Education for Advanced Practice Nursing –Provided schools with key content areas to be included in DNP curriculum –Provided guidelines, standards for development of courses (see Box 22.1)

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A doctor of nursing practice degree is a research-, theory-based degree.

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A doctor of nursing practice degree focuses on clinical practice, not research or theory.

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoughts of APRN Organizations The National Organization of Nurse Practitioner Faculties: acknowledgement that DNP worthwhile goal to attain National Association of Clinical Specialists: neutral position with ongoing dialogue American College of Nurse Midwives: DNP an option but not requirement for entry to practice American Association of Nurse Anesthetists: support DNP mandate with extension to 2025

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Issues and Concerns Timing of recommendation (other pressing issues) Concern that DNP does not include theory Impact of DNP on nursing education (PhD programs) Concern about faculty with DNP and tenure Apprehension related to rigor of DNP programs with other doctoral programs

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is being emphasized as the required degree for entry into practice for APRNs? A. Master’s degree B. PhD C. DNP D. DNS

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. The current belief is that the DNP should be considered as the degree required for entry to practice for APRNs.

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader ANA white paper of 2007 citing need for –Preparation for clinical leadership –Implementation of outcomes-based practice, quality- improvement strategies –Remaining in, contributing to profession –Creating, managing microsystems of care

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader (cont.) Increased pressure on nursing education to produce graduates with education, expertise to meet challenges of 21st century Ten assumptions for preparing CNL (see Box 22.2) Key area of focus: integration of care of all health care providers

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader (cont.) Expectations: –Provide, manage care –Critically evaluate, anticipate risks to client safety –Profile patterns of need, tailor interventions –Advocate for clients, community –Assume role of educator –Be responsible for care provision, management –Be member, leader of health care team

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader (cont.) Necessary skills –Systems thinking –Risk analysis –Quality improvement at the micro- and mesosytem level –Use of evidence-based practice –Ability to laterally integrate care over the health care continuum

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader (cont.) CNS controversy –Belief that CNL functions in manner similar to their practice –CNL, CNS with overlapping roles, competencies CNL: master’s-prepared advanced generalist nurse CNS: master’s-prepared APN with specialty

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Nurse Leader (cont.) CNL role: all patients receive special attention across care continuum, not just ones with certain diagnoses Statement of case for the role: –Humanize, personalize health care experience –Coordinator, change agent Role of CNL continues to be assessed in years to come

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A CNL focuses on a specialty area of patient care.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A CNL provides and manages care, integrating the care of all health care providers. A CNL is considered to be an advanced generalist nurse. A CNS is considered to be an advanced practice nurse with a specialty.

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins End of Presentation