Role Development Analysis Paper. Alfreda Lewis, RN. Auburn University/Auburn Montgomery

Transcription

1 Role Development Analysis Paper 1 Role Development Analysis Paper Alfreda Lewis, RN Auburn University/Auburn Montgomery

2 Role Development Analysis Paper 2 Introduction Change is one of the most frightening processes known to man, yet, it is the one constant that has propelled mankind from one scientific sphere to the next. Change is unavoidable; the telegraph was replaced by the telephone, television replaced the radio, and social websites such as Facebook have virtually replaced the mail system. Every aspect of life as we witness it today can be seen in almost real-time metamorphosis as mankind struggles to keep afloat of the political and economic factors driving present-day change. Evolution is necessary to meet the financial and health-related needs of the nation s millions, and nothing is more evident of this advancing shift from the state of business as usual as seen in the current presidential race with candidates divided on how uninsured Americans needs can best be served; that is, Obamacare or no care. Likewise, thanks to rapid societal changes and overwhelming drains on the delivery of traditional medical care in the early 20 th century, the nursing profession has undergone similar but well-deserved gains that frankly, are not met with acceptance by all professional team members; the very ones that these changes were designed to help. The elevation of nursing from its former position as nothing more than laborers, to a collective body of professionals backed by scientific research that defines its scope of practice, is one that all members are proud to proclaim. Today s nurses are encouraged to embrace change and strive for excellence and professional growth to meet the present and future demands of the American healthcare system. The Advance Practice Nurse (APN) is one of the most visible results of this changing political, financial, and economical climate which demands high quality healthcare that is cost effective. The multi-faceted roles of APNs are the subject of this paper and will be explored in further detail.

3 Role Development Analysis Paper 3 Necessity-The Mother of All Change To fully understand the strides that the advanced practice nursing profession has made, it is necessary to recognize the accomplishments made along the way. In 1861, there were very few professional nurses in the United States except for Catholic and Lutheran religious women called sisters and deaconesses. The Civil War resulted in an influx of thousands of women from over the country wishing to lend their hands to healing the injured and sick soldiers as nurses; unfortunately, because of societal restrictions, their duties consisted of little more than cooking, laboring, and bedpan duty. These restrictions did not hold true for the Catholic sisters who assisted in many areas including surgery. This assistance to the Civil War physicians was so invaluable, hospitals around the country opened schools for nurse training during the post war decade modeled after Florence Nightingale s school at St. Thomas Hospital in London (Hamric, Spross, & Hanson, 2009). Midwifery was delivered to the United States along with the slave trade in 1619 and remained a viable and respected part of community nursing until largely replaced by scientific, hospital-based delivery methods. The turn of the 20 th century brought with it one of the most dynamic changes in the nursing profession seen today. With the continued flood of immigrants to northern cities, excessive crowding with its inevitable infectious disease outbreaks became a problem. This newly industrialized nation established medicine as a respectable and economically viable male dominated profession. Nursing became regulated as a profession in 1903 with mandated state licensure; a significant step in role progression. The great depression of the 1930s dealt a major blow to the autonomous private duty nurse as work became unavailable and hospital-based nursing service overseen by male physicians became the only alternative. This change was very detrimental to nurses as they lost their ability to bill directly for their services thereby becoming lumped into the package price for general hospital services

4 Role Development Analysis Paper 4 (Hamric et al, 2009). In 1939, World War II caused an exodus of British nurse-midwives back to England as Britain entered the war. During that year, Mary Breckenridge established the Frontier Graduate School of Midwifery in Kentucky to train American nurses to compensate for the loss; a significant accomplishment. Opportunities flourished for nurses during World War II as the overwhelming need for care on the battlefront forced nurses to provide care that went beyond their usual scope of practice. This emerging specialty dictated by the health demands at that time helped to expand nursing beyond the previous established limitations and into the 21 st century. It was simply executed; if a physician was too busy with other cases, the nurse s role expanding from caring to curing. If the physician was readily available, the nurse was expected to practice within her usual caring role (Hamric et al, 2009). During the post World War II years, the federal government provided funding for nurse education leading to the establishment of the master s degree in nursing in These federal contributions in the post war era and all years following was critical to the advancement of the graduate program of nursing. These necessity driven changes in American history have afforded nurses many opportunities as well as inherent obstacles to the progression of nursing profession. Advanced Practice Nurse Role Development The term Advanced Practice Nurse is used to describe a nurse with specialized scope of practice and educational qualifications. Although its origin is unknown, MEDLINE and NURSING AND ALLIED HEALTH databases reveal no use of the term prior to 1985, long after the establishment of advanced practice roles (Gray, 2000). What is known is that the concept of advanced practice nursing dates back to probably the days of Adam and Eve when someone with advanced or midwifery skills delivered the firstborn son on earth. Lay midwifery can successfully be traced to ancient Greece and Egypt to which certified nurse-midwives owe

5 Role Development Analysis Paper 5 their existence. Opposition to CNMs has been significant in the past, largely due to disgruntled general practitioners who saw them as encroaching on their financial pot of gold. Today, many factors, including the feminist movement in the 1970s have caused resurgence in the popularity of non-hospital/traditional births with the number of CNPs engaged in direct patient greater than 50% (Gray, 2000). The controversy surrounding the roles of APNs has sparked much interest and debate in the past few years, especially as the profession seeks to move onward in its quest to be taken seriously as scientific counterparts of medical professionals. Gray cites Peplau (1965) as dating the origin of the term clinical nurse specialist (CNS) to 1938, whereas Norris (1977) attributes its origin to the National League for Nursing Committee (1944) that was studying postgraduate clinical nursing practices. Regardless of the continued controversy and barriers placed upon the profession by bureaucracy and high-power wielding insurance bigwigs, it is evident that the demands for quality health care will ensure the place of advanced practice nurses in modern medicine. The Multi-Faceted Roles of the Advanced Practice Nurse The rapidly changing complex of the modern healthcare system implores the nursing profession to creatively keep pace with the clinical needs of Americans. Advanced Practice Nursing is the umbrella for four established graduate level nursing roles: Certified Registered Nurse Anesthetist (CRNA), Certified Nurse-Midwife, (CNM), Certified Nurse Specialist (CNS), and Nurse-Practitioner (NP). Serious harm to the profession is done when trying to define the various roles by tasks rather than concepts which imply some APNs perform some areas of core competencies to the exclusion of others. The APN s abilities demonstrate extreme competency that surpasses basic qualifications to include high levels of self efficacy, creativity, and

6 Role Development Analysis Paper 6 innovation in complex situations while working effectively as part of a multidisciplinary team (Williamson, Twelvetree, Thompson, & Beaver, 2012). Nurses with advanced practice skills (assessment, diagnosis, and treatment) have been used in the U.S. and UK to relieve overburdened physicians in primary care settings. Many studies have attempted to distinguish APN role differences. A Clinical Nurse Specialist (CNS) uses advanced nursing skills and is an expert within a specialized area of nursing; the CNS functions as a consultant in her area of expertise in direct clinical (patient) care and within a given specialty whereas an APN works across specialties in the same manner as junior doctors (Williamson et al, 2012). The primary criteria for advanced practice nursing are: (1) earning a graduate degree in an advanced nursing practice role, (2) receiving licensure to practice, and (3) practice focused on patients and families. Healthcare agencies are continually faced with the challenge of providing high quality care for the least amount of healthcare dollars. The growing interest in APNs to meet this challenge has encouraged nursing to redefine itself to break away from traditional limitations. Present day nursing is knocking down previously set boundaries in its quest for more autonomy. Understanding what each of the advanced nursing roles offer is crucial to the improvement of healthcare delivery. Clearly defined roles can be met with support by physicians and insurance companies leading to standardized measures that can verify efficiency, cost effectiveness, and benefits to the patient (Lowe, Plummer, O Brien, & Boyd, 2011). The first advanced practice nursing role, the nurse anesthetist (NP), can successfully be traced back to the late 19 th century. The nurse anesthetist represents the oldest advanced practice role in modern nursing history and owes its evolvement to the introduction of nitrous oxide, ether, and chloroform in the mid-19 th century. Physicians were not particularly interested in this

7 Role Development Analysis Paper 7 aspect of surgery, so nurses eagerly assumed the responsibility of safely and effectively delivering anesthesia. Strained relationships between nurses and physicians have influenced modern practice as APNs have fought to retain the right to continue practicing these acquired skills. Despite attacks resulting in court actions as recently as 1986, more than 25,000 nurse anesthetists currently practice in the United States (Gray, 2000) The clinical nurse specialist role was conceived by nurses for nurses, unlike the roles of nurse midwives or nurse anesthetists. It has flourished in the hospital-based clinical settings as well as in schools of nursing. The first graduate program for CNSs was established in 1954 at Rutgers University in the area of psychiatric nursing (Gray, 2000).. As the term implies, CNS contains elements of both advanced and specialty practice and cannot be easily defined. Specialty practice is based on in-depth, detailed knowledge of a specific area of practice within the larger nursing discipline. This clinical expert practices in a variety of settings including education, community health, and mental health providing direct patient care. CNSs provide care in a range of specialty areas including cardiac, oncology, neonatal, and obstetrics (Kenward, 2007). Their expertise is valuable as researchers in cost and quality outcomes for organizations. The nurse practitioner role was established in 1965 in the University of Colorado s pediatric NP educational program. The program expanded from pediatric care to a family practice when the Family Planning Program was opened at the University of Washington; soon other programs were established that included adult, women s, and geriatric health. One of the most important events in history impacting the NP practice is the 1997 Budget Reconciliation Act which made payment for advanced practice services a reality (Gray, 2000). The impact of NPs on healthcare delivery is nothing short of phenomenal and continues to grow daily. From its conception, this role has been plagued with opposition because of its perception as a physician

8 Role Development Analysis Paper 8 substitute. NPs have survived what surely was a concentrated effort on the part of general practitioners to discredit the NP practice; surprisingly, these unfair tactics have resulted in greater demand for the alternative and efficient care that NPs provide. For instance, the development of new oral birth control methods and intrauterine devices in the 1970s necessitated the development of the obstetric/gynecologic NP and other APN programs promoted by Planned Parenthood (Fontenot, (2011). NPs are licensed independent professionals who practice in and hospital settings as primary providers in collaboration with a physician and other health care professionals. The NP s knowledge base must continually develop beyond the basic educational requirements in order to deliver safe, professional care. Although much discussion has been made about the similarity between CNSs and NPs, the glaring distinction lies in the NP s role of diagnosis and treatment (Lowe et al, 2011). It is also recognized that it is inevitable that NPs cross professional boundaries in the delivery of adequately managed care, combining some features of medicine along with nursing, but the overall result is the provision of holistic nursing care. Differentiating the Roles Through Regulation There continues to be confusion among various healthcare organizations as to the various functions of advanced practice nurses. Clarity concerning this issue assists boards of nursing in determining appropriate levels of regulations as well as aide in physician understanding and support of APN for the success of future healthcare initiatives (Kenward, 2007). The regulatory supervision for clinical nurse specialists and nurse practitioners is done by the state boards of nursing primarily. Other regulatory bodies include advanced practice nursing boards and health departments depending on various state legislation. Minimum educational requirements presently are a graduate degree with concentration in an advanced nursing practice

9 Role Development Analysis Paper 9 category. Prescriptive authority is not automatically granted to all nurses passing the educational requirements for practice, but is regulated by individual state legislation. Generally, prescriptive authority is independent but limited to the area of practice. An even greater variation in prescriptive authority is seen regarding controlled substances and varies according to state regulatory boards. The meeting of the 82 nd Legislative Session resulted in the passage of House Bill (HB) 2610 permitting nurses and other health professionals with a doctorate degree to use the title doctor with certain stipulations: the doctoral degree must be earned in the individual s field of practice; the individual is licensed by a state regulatory board in his or her field of practice; and is practicing under the license of a supervisor who is licensed by a health professional board to practice the profession in which the individual s doctoral degree is obtained (Klein, 2009). The American Association of Colleges of Nursing (AACN) has mandated that the advanced practice nurse education completion be elevated to the level of doctorate degree by year 2015 (Fontenot, 2011). Regulations governing these new requirements are in the planning phases as the world gears up for more controversy regarding physician/np duties. The Future is Bright The role of the advanced practice nurse will continue to evolve in response to changing economical and health care needs. The potential opportunities for NPs to solidify their places in healthcare currently and in the future are staggering. Despite opposition on many levels, the contributions made by early nursing pioneers and present day nursing-activists cannot be denied. We must continue the fight to reject the blending of CNS and NP roles which undermines the strong foundation the NP has worked so hard to build; that of exceptionally prepared autonomous and independent health care providers. Through support of nursing professional

10 Role Development Analysis Paper 10 organizations and political activities, APNs can secure their position in the wave of the future as providers of excellent alternatives to traditional medical care. So bright is the future of advanced practice nursing that competition for college placement will be immense, challenging professors to be innovative in meeting AACN s requirements for doctorate-prepared APNs. Creative use of technology, simulation labs, on-line courses, and on-line learning is essential for increasing the knowledge base and core curriculum for this next generation of nurses (Fontenot, 2011). With advanced practice nurses standing on threshold of universal healthcare in the United States, the demand for healthcare providers will increase. Advanced practice nurses are poised to help meet the demand of healthcare reform through standardization of APN roles, continued excellence in practice, ever- increasing knowledge bases, and unity of purpose.

11 Role Development Analysis Paper 11 References Fontenot, H., & Hawkins, J. W. (2011). The evolution of specialists in women's health care across the lifespan: Women's health nurse practitioners. Journal Of The American x. Retrieved from sid=a57c1b4c-60c4-45d4-838b-2a6e9233c54d%40sessionmgr14 Gray, M., Ratliff, C., & Mawyer, R. (2000). A brief history of advanced practice nursing and its implications for WOC advanced nursing practice. Journal Of Wound, Ostomy & Continence Nursing, 27(1), Retrieved from Academy Of Nurse Practitioners, 23(6), doi: /j b83-48c3-ad21- f4c057cb628d%40sessionmgr10&bdata=jnnpdgu9zwhvc3qtbgl2zq%3d%3d#db=cin 20&AN= Hamric, A. B., Spross, J. A., & Hanson, C. M. (2009). Advanced practice nursing: An integrative approach (4 th ed). St. Louis, MO: Elsevier/Saunders. Kenward, K. (2007). Role delineation study of nurse practitioners and clinical nurse specialists Retrieved from Klein, T. (2009). Advanced practice nursing: the four roles and titling. Oregon State Board Of Nursing Sentinel, 28(4), &site=ehost-live

12 Role Development Analysis Paper 12 Lowe, G., Plummer, V., O'Brien, A., & Boyd, L. (2012). Time to clarify - the value of advanced practice nursing roles in health care. Journal Of Advanced Nursing, 68(3), doi: /j x. Retrieved from 5fbba1c43230%40sessionmgr12&vid=8&hid=17 Williamson, S., Twelvetree, T., Thompson, J., & Beaver, K. (2012). An ethnographic study exploring the role of ward-based Advanced Nurse Practitioners in an acute medical setting. Journal Of Advanced Nursing, 68(7), doi: /j x. Retrieved from 5fbba1c43230%40sessionmgr12&vid=3&hid=17