Week 1 APRN – Patient Relationships, Scope of Practice, Trends, & Barriers – Flashcards

1. Scientific Foundation - critically analyzes data and evidence to improve practice, develops new practice approaches based on the integration of research, theory, and practice knowledge 2. Leadership - assumes leadership roles to guide change; fosters collaboration with multiple stakeholders to improve health care; advocates for improved access, quality, and cost-effective care; Demonstrates leadership that uses critical and reflective thinking; Advanced practice through the development and implementation of innovations incorporating principles of change; communicates practice knowledge effectively; participates in professional organizations and activities that influence APRNs and population health outcomes. 3. Quality - Uses best evidence to improve quality of clinical practice; evaluates relationships among access, cost, quality, and safety and their influence on health care; evaluates how organizational structure, care processes, financing, marketing, and policy decisions affect quality of care; applies skills in peer review to promote culture of excellence; is proactive in implementing interventions to ensure quality. 4. Practice Inquiry - provides leadership in the translation of new knowledge into practice; generates knowledge from clinical practice to improve practice and patient outcomes; applies clinical investigative skills to improve health outcomes; leads practice inquiry and disseminates information; analyzes clinical guidelines for individualized application into practice. 5. Technology and Information Literacy - integrates appropriate technologies for knowledge management to improve care; translates technical and scientific health information appropriate for various user's needs; Assesses patient and caregiver educational needs and coaches them to make positive behavioral changes; contributes to the design of clinical information systems that promotes safety, quality, and cost-effective care; uses technology that captures data on variables for the evaluation of nursing care. 6. Policy - Understands interdependence between policy and practice; advocates for ethical policies that promote access, equity, quality, and cost; analyzes ethical, legal, and social factors influencing policy development; contributes to the development of health policy; evaluates impact of globalization on health care policy development. 7. Health Delivery System - applies knowledge of organizational practices and complex systems to improve health care delivery; effects health care change using broad skills - negotiating, consensus-building, partnering; minimized risks to patients and providers; facilitates development of health care systems that address needs of culturally diverse populations, providers, and other stakeholders and evaluates the impact of health care delivery on these populations and the environment; analyzes organizational structure, functions, and resources to improve delivery of care; collaborates in planning for transition across continuum of care. 8. Ethics - integrates ethical principles in decision-making; evaluates ethical consequences of decisions; applies ethically-sound solutions to complex issues. 9. Independent Practice - Functions as licensed independent provider; demonstrates highest level of accountability for professional practice; practices independently managing previously diagnosed and undiagnosed patients; provides full spectrum of health care services; uses advanced health assessment skills to differentiate between normal and abnormal; employs screening and diagnostic strategies; prescribes medications within scope of practice; manages health/illness states of patients and families over time; provides patient-centered care recognizing cultural diversity and the patient as a full partner in decision-making; establishes relationship with patient characterized by mutual respect, empathy, and collaboration; creates climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect; incorporates patient's cultural and spiritual preferences, values, and beliefs into health care; preserves patient's control over decision-making by negotiating a mutually acceptable plan of care.

Uniform definition of advanced practice nursing for the purpose of regulation; Result of collaboration of many major nursing organizations; Consistent with "Future of Nursing" report from the IOM; Consists of APRN specialties based on roles and populations. 4 categories - NP, CNS, Nurse Midwives, and CRNA Specialties - 6 population foci An APRN is a nurse who meets the following criteria: -completes an accredited graduate level education program that prepares her for one of the four APRN roles and a population focus. -Passes a national certification exam and maintains continued competence by national recertification -Possesses advanced clinical knowledge and skills to provide direct care to patients. -Builds on competencies of RNs by demonstrating greater depth and breadth of knowledge and greater synthesis of data by performing more complex skills and interventions and by possessing greater autonomy. -Is educationally prepared to assume responsibility and accountability for health promotion and maintenance, as well as diagnosis and management of patient problems, including the use of prescriptions -Has sufficient depth and breadth of clinical experience to reflect intended licensure -Obtains license to practice as an APRN in one of the four APRN roles.

Nurses should practice to the full extent of their education and training. Remove scope-of-practice barriers. Amend Medicare to authorize APRNs to perform admission assessments and certification for patients for home health and admission to hospice and skilled nursing facilities. Expand Medicare to include coverage of APRN services just as physicians are covered. Extend increase in Medicaid payments to APRNs. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless progression. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Implement nurse residency programs. Ensure nurses engage in lifelong learning. Prepare and enable nurses to lead change to advance health. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the U.S. Effective workforce planning and policy making require better data collection and improved information infrastructure.

Conceptual definition of advanced practice nursing and defining characteristics that include primary criteria (graduate education, certification in specialty, and focus on clinical practice with patients) and set of core competencies (direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision-making, consultation, and leadership). Critical environmental elements affecting advanced practice nursing include - regulatory and credentialing requirements, business aspects, health policy, payment mechanisms, outcome evaluation and performance improvement, marketing and contracting, and organizational structure and culture.

Did the clinician do the right thing at the right time? Was effective care provided to the patient? Was care provided safely and in an appropriate time frame? Was the outcome as good as expected, given the patient's condition and personal characteristics and the current state of medical science? Standards are set by the National Committe of Quality Assurance (NCQA), Joint Commission, Medicare, and the Agency for Healthcare Research and Quality (AHRQ). AANP - Standards of Care 1. Assessment of health status (health history, PE, identifying risks, ordering appropriate testing) 2. Diagnosis (critical thinking, analyzing data, differential diagnosis, establishing priorities) 3. Development of treatment plan (ordering additional tests, prescribing appropriate interventions, developing education plan, appropriate consults/referrals) 4. Implementation of plan (individualized, consistent with care plan, consistent with teaching and learning opportunities) 5. Follow up/Evaluation (determination of effectiveness of treatment plan with documentation of outcomes, modifying plan as necessary)

Health Plan Employer Data and Information Set Set of performance measures set by the NCQA.

Inconsistent state-by-state regulations Physician "supervision" or "collaboration" requirements Invisible provider status through "incident to" billing Inability to order hospice, home health care, or skilled nursing services Unable to practice NP principles of care that is patient-centered, health-focused, and holistic within a particular setting due to role fulfillment constraints. In many clinical settings the medical model dominates leading to restricted nursing aspects of care. Lack of recognition of nursing diagnoses as billable conditions. Language difference and confusion about the APN role. Lack of collective voice. In some states, state board of nursing does not have sole power to govern nursing practice in the state (Missouri). (Internal barriers relate to the role of the nurse practitioner. External barriers are primarily related to public policy. )

APRNs must obtain their right to administer, dispense, or prescribe drugs through a collaborative practice agreement. Also, APRNs are not allowed to prescribe controlled substances unless specifically outlined in the collaborative practice agreement (however, APRNs are NOT allowed to prescribe schedule II meds, and no more than a 5 day supply of schedule III meds). Missouri statutes state "when a collaborative practice arrangement is utilized to provide health care services for conditions other than acute self-limited or well-defined problems, the collaborating physician . . . shall examine and evaluate the patient and approve or formulate the plan of treatment . . .no more than 2 weeks after the patient has been seen by the collaborating APRN." Upon entering a collaborative practice agreement, an APRN must practice on site with the collaborating physician for a minimum of 30 days. After this period, the APRN must practice within a 30 mile radius of the collaborating physician in a non health professional shortage area, and within a 50 mile radius of designated health professional shortage area. The collaborating physician must sign at least 10 percent of the APRNs charts overall, including at least twenty percent of the charts in which the patient was prescribed controlled substances. The charts must be submitted for review every 2 weeks. APRNs in Missouri are not allowed to sign death certificates, but are allowed to sign handicap parking permits.

1. Patient advocacy 2. Education 3. Change Agency 4. Case Management 5. Consultation (Direct patient care is primary role)

Fundamental to nursing practice A way of being in a relationship in which the NP sees the patient as a whole human being in their experience with health & promotes uniqueness of client Respect for individual is what guides nurses' advocacy Types - Legal, moral-ethical, substitutive, political, spiritual, advocacy for nursing, advocacy for community health

Nurse is supportive of patient's legal rights, such as informed consent or right to refuse treatment Ensure all patients have a copy of the institution's bill of rights

Requires that the nurse respects the patient's value and supports decisions which are consistent with those values

If patient is unable to express his/her opinion, the NP should continue to respect the rights of the pt and support the prior wishes of the patient that may have been expressed.

Includes work to change laws and policies to assure equities for all patients, groups, and societies

APN assures that patient has access to spiritual support, such as clergy and the plan of care includes spiritual aspects of care.

Directs NP to be supportive of other nurses in their professional growth and supportive of the evolution/contribution of the nursing profession.

NPs must advocate for the assessment of health needs in a community, consider priorities for care and resources, and determine health and environmental trends that may impact a community.

Adult Learners - self directed; needs sense of involvement and control; experience is a rich source for learning; readiness to learn occurs with a perceived need to know or do something; orientation to learning is problem-centered or task-centered; Internal motivation is more potent than external motivators. Must first assess patient's knowledge base and readiness to learn. Planned content series most effective. Proceed from simple to complex. Build on what is known to learn unknown. Use terminology that is familiar to the learner. Set short-term and long-term goals. Plan a sequence of incremental learning activities and apply content to enhance learning. Use positive reinforcement. Evaluate outcomes of learning process.

Collaborative process for the promotion of quality care and cost-effective outcomes to specific patients and groups. Key features - standardized resources for length of stay for selected patient care, caregiver and system outcome; collaborative team practice among disciplines; coordinated care over course of illness; job enrichment for the caregiver; patient and physician satisfaction with care; minimized costs to institution. Types - 1. Patient-focused Model - supports the patient though the continuum of care helping them access care. 2. System-focused Model - involves service environment and is structured for cost containment of a specific group of patients and uses critical pathways for cost-effective outcomes. 3. Advanced Model - more comprehensive; incorporates cultural competency, consumer empowerment, clinical framework, and mutidisciplinary practice in addition to other activities of assessment, service, planning, implementation, coordination and monitoring, advocacy, and termination. Focus on patient empowerment, outcome measurements, and performance-based expectations. APRNs are good at interdisciplinary coordination, advanced clinical decision-making, autonomy, synthesis, and critical thinking. Best focused in health and disease prevention.

An individual who identifies, plans, implements change that is needed to survive. Must have resilience, flexibility, creativity, and responsiveness. Recognizing need for change is critical. Change should: 1. be integral to and focused on the strategy of the organization 2. leading to high performance 3. helped by the energy and creative ideas of people in the organization 4. supported by empowered and motivated employees 5. driven by specific consumer needs 6. guided by a limited number of balanced performance measures 7. able to build revenue 8. institutionalized in a culture that values continuous improvement.

3 Type of Change in an Organization: 1. Developmental - improvement in things such as skills, methods, or performance standards. Usually accomplished by sharing information and Process Improvement. 2. Transitional - Replaced current situation with something new (doesn't just build on); Needed when problem exists, an opportunity for something is not being pursued, or something needs to change or be created to serve current/future demands. 3. Transformational - Most complex; Moves from one state of being to another by changing culture, behavior, and mind-set; required when leadership is aware that the current process must be changed to reach objectives and the scope of this change is so significant that it requires a fundamental shift in peoples culture, mind-set, and behavior to be successful.

1. Unfreezing - realizing need for change 2. Moving - forces for change are identified and altered 3. Refreezing - established new equilibrium

1. Use performance measures appropriate to the plan - avoid the old, long-established measures; 2. Assure that competing projects support the other and are not divisive or competitive 3. Listen and involve your consumer 4. Involve employees in the project to help build commitment 5. Assure that management is well informed, have a stake in the plan, and endorse the plan 6. Possible problems - failure to deliver early results, which will reduce support; drowning in details, must focus on outcomes - not process; Must prioritize goals 7. Explain how change will improve situation, make it tangible 8. Assure that change is based on organization's facts and is tailored to organization's needs; Avoid implementing something that worked elsewhere 9. Engage other employees, not just ones involved.

APNs may be external (outside organization) or internal (inside organization) consultants. Can be considered a primary vehicle for the dissemination of APRN expertise. 4 Categories: 1. Client-centered case consultation 2. Consultee-centered case consultation 3. Program-centered administrative consultation 4. Consultee-centered administration consultation

1. Laying the Foundation - period of role identity confusion immediately post-graduation; not yet an NP but no longer a student; feelings of worry, confusion, insecurity; Developmental tasks - recuperate from school, initiate job search and secure position, obtain certification; Refine profession portfolio 2. Launching - discomfort of advanced-beginner level of knowledge and skills; feelings of unreality, insecurity, "imposter phenomenon"; performance anxiety; daily stress; time pressure; Developmental tasks - develop realistic expectations, incorporate feelings of legitimacy into NP role identity, cope with anxiety, mobilize problem-solving skills, work on time management and setting priorities, develop support system 3. Meeting the Challenge - decreased anxiety, increased feelings of legitimacy, increased confidence and competence, increased acceptance and comfort with uncertainty inherent in primary care; Developmental tasks - expand recognition of practice concerns to include work environment, gain situated knowledge and skill in managing clinical problems, identify tangible accomplishments, develop individualized style of approaching patients and organizing care; gain ability to handle uncertainty 4. Broadening the Perspective - feelings of enhanced self-esteem; solid feeling of legitimacy and competence; realistic and positive feelings about future practice; developmental tasks - acknowledge strengths and identify ways to incorporate additional challenges; identify large system problems and seek solutions; continue role evolution and skill development; share expertise and experience though publications, research, professional activities, mentoring, maintain flexible approach; be alert for complacency or boredom

1. Assessment 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation - coordination of care, health teaching, health promotion, consultation, prescriptive authority and treatment 6. Evaluation 7. Ethics 8. Education 9. Evidence-based practice and research 10. Quality of practice 11. Communication 12. Leadership 13. Collaboration 14. Professional Practice Evaluation 15. Resource Utilization 16. Environmental Health

Assists in nursing's self-regulation of practice Scope of practice - legal authority granted to a professional to provide and be reimbursed for health care services. NPs have the legal authority to examine, diagnose, treat, and educate their patients. Standard of Care - a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. Used by attorneys and medical expert witnesses use in court of law to determine malpractice, neglect, etc.

1. Clarified what is an APN and the role of graduate education and certification in licensing APRNs 2. Ensuring APRNs are fully recognized and integrated in delivery of health care 3. Reducing barriers to mobility of APNs across state lines 4. Fostering and facilitating dialogue among APN stakeholders 5. offering common language regarding regulation

Licensure - granting of authority to practice Accreditation - formal review and approval by recognized agency of educational degree or certification programs in nursing Certification - formal recognition of skills, knowledge, and experience demonstrated by achievement of standards identified by profession. Education - formal preparation of APRNs in graduate education