Advanced nursing practice is recognized as an advanced level of nursing care that uses in-depth nursing knowledge and nursing expertise to meet health care needs. Unlike traditional nursing practice, advanced nursing practice involves numerous streams of activities like: analysis, knowledge synthesis, critical thinking, decision making, interpreting, evidence based practice and managerial/administrative roles. The evolution of advanced nursing practitioners happened when nurses were expected to take extra responsibility in addition to their traditional role. Due to lack of a sufficient number of doctors to attend to people in remote areas and in families, nurses were given the added responsibility to work with special care settings and discharge healthcare duties in places where care providers were deficient. These extra burden of responsibilities, added to the need to train nurses in advanced practicing knowledge and skills. The expanded roles and responsibilities required more skill and knowledge. (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004)
The main impetus for the development of advanced nursing practice courses was the shortage in trained nursing staff to handle the challenges of the evolving healthcare system. The federal government allotted more funds to train nurses, so as to meet the healthcare needs of the society. The evolving health care system provided an opportunity for nurses to develop their professional skill and also provided opportunities where nurses can function in an independent manner. Nursing is now recognized as a profession in itself, rather than as an adjunct to the physician. Nurses and physician have unique roles in a healthcare set-up and advanced nursing practitioner are involved in the maintenance and continuum of health care. The nursing curriculum has evolved over the years to meet the new challenges. It not only trains the nurses to act in collaboration with a physician, it also emphasizes the importance of their independent role in health care delivery. (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004)
i. Role of APN as an advocate: The international council of nurses has included advocacy as an important nursing role for advanced nurse’s practitioner. In this role, nurses will help to meet the social and national health needs and will promote efforts in this direction. Advocacy refers to the participation of the nurses, along with the client in the decision making process. They provide professional help to the client, that will enable him to make an informed decision. At the same time, the nurses are expected to remain uninvolved with influencing the client’s autonomy and independence while making decision. (Hewitt, 2002)
Nurses can provide different levels of advocacy. At the level of the family and individual, nurses help to identify health concerns and health services that will help them meet their health needs. At the level of an organization or institution, they can be advocates of change for a better health care system and delivery. The most common model of advocacy, followed in advanced nursing practice is the counselling paradigm, which is the most dominant model. In this model, the nurses offer advice, information and counselling, taking into consideration the ethico-legal framework of human right. Hence, knowledge on ethical and legal matter connected to patient rights and health care delivery, is essential for advanced practice. The other less common model of advocacy is the consumer empowerment model. This is applicable to consumers who seek professional help to navigate through the complex health care system. In the Sullivan strength based management model, nurses advocate change, after identifying gaps in the functioning of the system. This method of advocacy, helps to provide solutions to management problems. Nurse’s advice, is also sought in developing policies and programs that support health and human welfare. The ability of the nurse to be assertive enough and the ability to collaborate with a team, make them ideal candidates to advocate change. Though communication with fellow nurses, patients, families, clinicians and members in the community, nurses can promote change towards a better health care. They can advocate change by acting as role models, mentors or preceptorships. Nurses act as agents of change through collaboration and consultation with decision makers and care providers. (Hewitt, 2002)
ii. Role of APN in research and evidence based practice: Specialization, expansion or acquisition of new knowledge and autonomy are the three characteristics of advanced nursing practice (APN). During the graduate learning process, the knowledge advancement is achieved by integrating theoretical, research based and practical learning experiences. This advancement in the knowledge of the nurses helps to orient them to the advanced level of practice that is expected of them. During training, nurses also learn knowledge synthesis skills and the professional ability to evaluate clinical intervention and care delivery. (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004)
Advanced nursing practice is based on the foundation of established nursing theories and scientific evidences. Through translational research, the scientific evidences in a laboratory setting, is applied to clinical practice. There are number of factors that hinder the direct application of laboratory finding to practice. Translational research helps to bridge the gap between theory and practice. On the other hand, evidence based nursing practice, involve the application of established nursing theories and validated research findings into practice. Through translational research, nurses get to learn the condition, cost and resources that are required to convert a progressive theory into evidence based practice. (Butts & Rich, 2014)
Healthcare is going through a period of reforms that assures safety and quality of care. The quality improvement reforms are based on the evidences provided by theories and research findings. Translational research acts as a foundation for scientific evidences used in clinical practice. As evidence based practice has become the norm of the healthcare, nursing theories will guide clinicians, nurses and organizations in translational research. (Butts & Rich, 2014)
Five types of theories govern the pattern of knowledge gained through translational research: empirical theories, aesthetic theories, ethical theories, personal knowing theories and sociopolitical theories. Translational research helps to integrate the above theories, so as to guide evidence based practice. Seven fundamental steps are identified in the conversion of translational theories into evidence based practice. The first step in the process is to identify practical problems in health care delivery. In order to identify a problem, a nurse must possess the necessary knowledge, skills and experience. This will help the APN to consider possibilities and ways that will help to assess the problems and initiate intervention required to overcome the problem. A number of factors like: patient experience, workshops, journals and position statements can create awareness about the problem in the APN and help to identify problems in the unit of health care. (Butts & Rich, 2014)
The second step is to develop research questions based on the understanding of the problem. The PICOT format was developed to guide a nurse in developing an effective research question. It takes into consideration five aspects of the research question: patient population to which the problem is applicable, intervention or area of interest of the research question, group comparison, desired outcome and time. (Butts & Rich, 2014)
The third step is to search the existing literature, so as to find an answer to the research question. The literature is critically evaluated during this process. Searching the literature will help to understand the volume of work that has been done on the topic or area of interest. This also helps to identify evidence based tools supported by literature. Conceptual models and PICOT format can help to provide search terms for retrieving literature from the databases. Best practice, guidelines and review summaries can also help to guide the literature search. (Butts & Rich, 2014)
In the fourth step, the literature is critically evaluated through the process of review synthesis. This evaluation process helps to explain the relevance of the research finding in addressing the research questions. A realistic review helps to understand how research tools and evidences work in a certain context. The review process also facilitates the integration of theoretical and practical knowledge. A worksheet is used to record the research findings for the retrieved literature. It can be used to assess the quality of the research evidences presented in the literature review. The evidences identified through literature review are graded for its feasibility, appropriateness, meaningfulness, effectiveness and economic value. (Butts & Rich, 2014)
The fifth step is to integrate evidence into practice. The evidences from literature is integrated with patient needs and in the context of the situation. It can be used to guide clinical judgement and to guide the patient in decision making. Pragmatic adequacy of the evidence is the extent to which theory serves as evidence for practical action. The pragmatic adequacy theory takes into consideration four factors: social meaningfulness, compatibility, feasibility and consistency. Social meaningfulness refers to the extent to which the translation of theory into practice can address patient needs. (Butts & Rich, 2014)
In the fifth step, the feasibility and compatibility of applying the theory into practice is evaluated and implemented. The sixth step follows after the implementation of the theory into practice. Following implementation, the theory is evaluated using research projects and quality assurance programs. This step will help to determine if the theory was effective in bringing about the desired effect. In the seventh step, the results of the evaluation process are disseminated through public presentation or publication in appropriate journals. (Butts & Rich, 2014)
Advanced nursing practitioners are expected to be skilled in reviewing and evaluating current research findings, so as to determine their applicability in the practice setting. Advanced practice nurses act as leaders in evaluating, translating and helping others to utilize theories. (Butts & Rich, 2014)
iii. Role of APN in clinical expertise and patient management skills: The new capitated reimbursement schemes have increased the pressure on hospitals to reduce the stay of inpatient in the hospitals. The aim of clinical expertise and management is to hasten the healing process and discharge the patient at the earliest. Unlike in the past, patients today are treated by a team of health care personnel. As a consultant healthcare worker, nurses work in advisory capacities. The patient may consult an APN for an initial assessment or to facilitate a decision making process. As a clinical consultant, nurses serve the function of contacting the client, identifying needs and discussing the possibility of a health care plan. Establishing a helping relationship with the client is a part of APN job responsibility. Following this, the nurses collect history that helps to identify the client’s problem. They can also undertake other assessments that will help in the diagnosis. Following this, the nurses take action based on expert opinion. The action of the nurse is expected to be in line with the principles of patient centered care. The nurses can also follow up on the patient, to evaluate progress. The patient is at the liberty of accepting or rejecting the advice offered by the nurse consultant and thus the accountability of implementation of treatment is not completely vested with the APN. (Benner, Tanner, & Chesla, 2009)
Clinical expertise will depend on the knowledge, skill, experience and confidence of the APN. Though the level of competency may be lower in an APN who is beginning clinical practice, the competency is expected to evolve with practice and experience. In many states in U.S, APNs is allowed to attend to the client directly and offer patient centered consultation. As a provider of clinical expertise, APN must be able to relate comfortably to the people concerned and attend alertly and critically to patient information and health care needs. They must also have the necessary skills to solve the health problem. Communication skills, problem solving skills and teamwork, are important part of clinical practice. In addition, self-awareness, time management, interpersonal skills, priority setting and the ability to identify an area of influence is very important in case management. To achieve such skill, nurses are trained in leadership, administration, organizational structure and in transcultural concepts. APN is expected to act considering the cultural sensitivity of the population they treat. While physicians have skills that enable a deep understanding of disease and treatment, APN consultants have the skills to appreciate the human response in diseases and illness. APN consultation is sought in care homes, home care, primary care and community health care centers that handles less specialized health concerns.
Nursing is a combination of art and science. Nurse practitioner use technical skills to provide humanistic care. Only a nurse who is an expert in clinical knowledge and is clinically competent, can make a sound clinical judgement. Such advanced practicing nurses are essential component of a clinical team and the nurse’s role in the team, is determined by the nurse’s competencies. Clinical care, leadership, management, quality of care and development of self are different domain where the APN’s competency can be employed. APNs are accountable for the decisions they make. They make decision on admission and discharging of the patient, they collect clinical history, conduct physical examination, determine diagnosis, direct referrals and are also given the opportunity to make prescription. These are some of the competencies that are expected from an APN. From being an assistant for physicians, APN has evolved to handle clinical cases in an autonomous and independent fashion. Nurses can also choose to specialize in certain chosen stream like for example: gerontology, diabetes, cardiology, etc. (Benner, Tanner, & Chesla, 2009)
iv. Complementary therapy and APNs role in guiding its inclusion into practice: According to the WHO estimates, ~80% of the world population use complementary medicine for at least some aspect of healthcare needs. The increasing interest in complementary medicine and the drive to incorporate it into conventional healthcare system, has led to increased funding to determine the clinical safety and efficacy of this medicine. This requires that APNs are informed of the clinical findings and the data related to the use of complementary medicine in health care. The National Centre for Complementary and Alternative Medicine (NCCAM), a body of the National Institute of Health, has been exploring the safety and efficacy of alternative healing practice through rigorous science. APNs can avail the online database of NCCAM, to enhance their knowledge on complementary medicine. The website of the National Institutes of Health's Office of Dietary Supplements, also provides reliable data on the safety and use of different dietary supplements. The APNs can use the information from these resources to guide patients in complementary medicine. Complementary medicine is based on the theory of holistic approach in treating a disease. Complementary medicine is not new to nursing. Before the advent of pharmacological revolution and technologies, nurses largely relied on complementary medicine for providing care. As a health care worker, APNs are expected to have awareness of the different health care practices in the culturally diverse population. (Hamric, Hanson, Tracy, & O'Grady, 2014)
Though complementary medicine may seem safe at the outset, it can interact with other pharmacological agents and practices prescribed to the patient, resulting in harmful side effects. While allopathy medicine is effective in treating acute or emergency situations, it may be too aggressive and replete with side effects while treating chronic conditions. Some practitioners choose to treat chronic diseases through an integrative approach that combine allopathy with complementary medicine. (Hamric, Hanson, Tracy, & O'Grady, 2014)
v. Teaching plan that a APN could use: As patient educators, APNs teach patients the skill of self-monitoring, life style management and medication administration. Both clinical expertise and the passion for teaching are pre requisite for a APN, so to gain rewarding outcomes. A teaching plan is made after accessing patient concerns and ability to learn. The teaching plan incorporates realistic learning objectives and resources for teaching are selected taking the patient into consideration. It is not necessary to teach the patient everything one knowns on the subject. The teaching is based on what the patient wants to learn and the concerns that the patient wants to address. The patient is provided only the amount of information that they can handle. The information is provided in an organized and comprehensive manner. The APNs may also adjust the education plan, following an evaluation of patient health response and changes in environmental factors. (Updated by: Jennifer K. Mannheim, 2016)
vi. Cultural and linguistic challenges of APN: Today healthcare caters to the need of a culturally diverse population in the U.S. The culture and linguistic barriers can hinder the acquisition of health literacy skill. APNs is thus given the added responsibility of integrating cultural and linguistic consideration while planning health care. Being a front desk executive, they are in an ideal position to discharge this job effectively and can contribute in promoting health literacy in this diverse culture. (Singleton & Krause, 2009)
Culture influences a person’s belief system. It dictates his behavior, perceptions, preferences and communication patterns. It also influences the role of the individual in his family and community. The average health literacy score of the minorities like Black, Hispanics, American Indians, are lowers than Whites and Asians. Health literacy can affect health outcomes of the patient. People with low health literacy are more likely to fall ill and have adverse health consequence when compared to others. The conflict and the discomfort that these minority culture faces, while trying to apply the practices of the dominant health care system, could be the reason for the poor health literacy. The culture and language of a person, can interfere with the effective communication between the patient and the nurse. Health literacy is required for critical thinking and decision making. Patients from the minority culture may have difficulty in enrolling and utilizing health care facilities and navigating through the bureaucratic procedures or paper works. APNs acts as providers of health literacy to a culturally diverse population. For these reasons, APN needs to have the appropriate self-awareness about people’s culture and their background. This will help to put aside their personal biases and beliefs, to help the patient. (Singleton & Krause, 2009)
vii. Techniques to solve conflicts arising in practice: Conflict arises in workplaces and practice, when interest, goals and belief of the stakeholders involved in the conflict, interfere with one another. Different people have different priorities, and the conflict arises due to difference in perception of a situation. Conflict need not be always a bad thing, very often they offer opportunity for improvement. Conflict resolution techniques will help deal with conflicts in a better way. One way of resolving conflict is by forcing once viewpoint at the expense of another person’s viewpoint and maintaining firm resistant. It should be the last option to solve a long lasting conflict, as it tends to affect relationship negatively. Another way of dealing with a problem is through confronting it and trying to solve it in a win-win situation. This is particularly important when a long term relationship is important. Compromising is a form of resolution technique where both parties agree on a mutually beneficial solution. Other resolution techniques involve withdrawing once viewpoint and accommodating. ("Conflict Management Techniques", 2016)
References
Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice (2nd ed.). New York, NY: Springer Pub. Co.
Bryant-Lukosius, D., DiCenso, A., Browne, G., & Pinelli, J. (2004). Advanced practice nursing roles: development, implementation and evaluation. J Adv Nurs, 48(5), 519-529. http://dx.doi.org/10.1111/j.1365-2648.2004.03234.x
Butts, J. & Rich, K. (2014). Philosophies and theories for advanced nursing practice (2nd ed.). Jones & Bartlett Learning.
Conflict Management Techniques. (2016). Personalityexplorer.com. Retrieved 10 June 2016, from http://www.personalityexplorer.com/FREEResources/ConflictManagementTechniques.aspx
Hamric, A., Hanson, C., Tracy, M., & O'Grady, E. (2014). Advanced practice nursing (pp. 169-300). St. Louis: Elsevier.
Hewitt, J. (2002). A critical review of the arguments debating the role of the nurse advocate. J Adv Nurs, 37(5), 439-445. http://dx.doi.org/10.1046/j.1365-2648.2002.02110.x
Singleton, K. & Krause, E. (2009). Understanding Cultural and Linguistic Barriers to Health Literacy. The Online Journal Of Issues In Nursing, 14(3), Manuscript 4. http://dx.doi.org/10.3912/OJIN.Vol14No03Man04
Updated by: Jennifer K. Mannheim, a. (2016). Choosing effective patient education materials: MedlinePlus Medical Encyclopedia. Nlm.nih.gov. Retrieved 10 June 2016, from https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000455.htm
