Four Roles of Advanced Practice Registered Nursing
Question:
Discuss about the Clinical Education And Training Of Student Nurses.
Advanced Practice Registered Nursing (APRN) comprises of four roles which are nurse mid-wife, clinical nurse specialist, nurse anaesthetist and nurse practitioner. Nursing practitioners are registered nurses with an accredited graduate degree and specialization certifications reflecting the area of expertise (Nursing.upenn.edu, 2018). Independent Nursing Practice allows the nurses to carryout work independent of other healthcare professionals, and also allows collaboration whenever required. This means that the nursing practitioners can practice and prescribe medications independently (Rigolosi & Salmond, 2014).The Independent nursing practice model comprises of models that are small business or private and are very mobile, which means that the nurses often have to travel to client’s locations. This model combines the functions of a small business ownership and a professional practice, which raises are significant challenge in respect to the combination of responsibilities associated with each of these functions (Hamric et al., 2013).
In the current context, the Independent Nursing Practice model will be critically analysed and evaluated to identify the strengths and weaknesses in the model. Opportunities for collaboration with other professionals in order to support the service model shall also be discussed, which can allow improvement in the model. Furthermore, the different barriers and challenges for improvement will also be analysed which can help nib the development of improvement strategies for the model.
The setup for the independent practice is setup in an aged residential care centre (Blue Care) which houses about 100 residents of ages 70 to 100 years.
Independent Nursing Practice involves the providence of differential services depending upon the local demand as well as the scope of the nursing practitioner, showing a lot of flexibility in practice. This entails the independent practice to be conducted at different service environments. Independent NP can provide non acute care in a home setup (MacPhee & Borram, 2012). The types of care provided can include: regular monitoring of blood glucose, blood pressure, and blood clotting; regular health checkups; care for wound; treatment for upper respiratory system, continence care, assessing the medication provided, assessment for falls and also provide referral for other services.
In the present scenario, the selected population comprises of elderly patients.
Independent NP enables the nursing practice to be conducted without the supervision of a physician. This helps the nurses to gain independence and autonomy as they are able to provide medical care without management or oversight of the physician (Antohe et al., 2016). A ‘full practice’ status of an NP is a provision that enables independent assessment, diagnosis, interpretation of diagnostic tests, and prescription of medicines (Moran et al., 2016). Licensed Independent Nurse Practitioners can conduct their practice in different setups like: ambulatory, acute, long term care and also function as primary or speciality care providers. They can assess, diagnose, treat and manage both chronic conditions as well as acute episodic conditions. Therefore the practitioners need to be adept with health promotion and disease prevention. They can also order, conduct, supervise as well as interpret laboratory and diagnostic results, provide prescriptions for pharmacological substances and non-pharmacological therapies. Moreover, the independent nurses can also be involved in teaching and counselling of the patients. Hain and Fleck (2014) however pointed out that many professional healthcare organizations do not support independent nursing practice as they believe that physicians have better competency in medical care compared to Nursing Practitioners due to their rigorous training, and hence NP are incapable of providing care within the same quality and safety parameters as physicians (Hain & Fleck, 2014).
Independent Nursing Practice Model for Nurse Practitioners
According to the Australian Department of Health, endorsement from Nursing and Midwifery Board of Australia is required to work as a nurse practitioner. The endorsement can be received on the merit of several factors like a general registration as a registered nurse with no restriction on practice; advanced practice in clinical leadership in the area of expertise in the last 5 years and complemented with research, education and management; showing competence in the competency standards set by the Nursing and Midwifery Board of Australia, and completion of the required qualification as mandated by Nursing and Midwifery Board of Australia. Such factors can ensure the development of competency, expertise and knowledge of the nurses to independently conduct their practice (nursingmidwiferyboard.gov.au, 2018).
The practitioners can work with individuals, families or communities in different care settings like hospitals, community health settings and private practice. However, there isn’t any limit on where an independent nursing practitioner can work, and currently in Australia Nursing Practitioners are involved in speciality areas like: aged care, emergency, drug and alcohol, private practice, surgical, medical, women’s health, rural and remote setup, mental healthcare facilities, communities, chronic and complex care centre as well as paediatric units (Nursing.upenn.edu, 2018). This also increases accessibility to healthcare services, as well as increase the range of care settings that can be supported by healthcare organizations.
In each of such settings, the consumer population needs, social determinants of health and primary healthcare principles can differ. In an aged care centre, the NP needs to deal with elderly patients. The health needs of the elderly population are underlined by the higher prevalence of chronic conditions, physical disabilities, mental health conditions, and related co-morbidities. Shrivastava et al. (2013) suggested that the health needs of the elderly patients cannot be viewed in isolation. This is because of different inter-related factors that can be attributed to the various health problems seen among them. Several determinants of health that affects the well being of the elderly has been identified by different authors, and includes: social factors (isolation of the patients, due to their children moving out in search for occupation), mistreatment of the elderly, lack of awareness about the risk factors, dietary and nutritional needs, psycho-emotional factors (like mental stress and isolation), financial factors (reduction of income after retirement thereby challenging the access to basic needs like proper nutrition, shelter and clothing), factors attributed to healthcare systems (healthcare insurance for elderly and government care facilities) and physical determinants. These factors can significantly affect the medical problems of the elderly, and also have an impact on the quality of life experienced by them (Song et al., 2013; Braz et al., 2012). INP can ensure provision of care that spans across several of these social determinants, providing a multi-dimensional care for the patient.
Shrivastava et al. (2013) proposed that prevention and control of health issues among the elderly populace requires a multidimensional approach that requires an active collaboration of different sectors like healthcare, social welfare, urban/rural development and legal, which can be a significant challenge considering the diverse range of professional skills required to maintain communication with them. Also, a lack of comprehensive policy that addresses the determinants of health is a weakness of this service. A community or a home based care program for the elderly patient’s needs to begin with the development of a comprehensive policy that can include the other determinants of health apart from the medical aspects. A strong sense of commitment and social action is needed for the proper implementation of the care model at the basic level. Improving the knowledge of the elderly about health and risk factors is an important measure, as pointed out by Song et al. (2013).Other measures include social measures that involves creating a culture where care of the elderly is also participated by their children; involving regulatory strategies that enables members of society to care for their aged parents developing health insurance policies for the elderly to cover their healthcare needs; developing pension schemes; development of elder friendly houses and roads; promoting primary prevention strategies like healthy lifestyle; providence of education, information and communication for the elderly, middle aged (individuals who will move on towards elderly age group in the near future) and the youth (acting as caregiver for the elderly) about issues related to hygiene, physical exercise, nutrition, avoiding alcohol and tobacco, accident prevention and developing awareness about the early signs of geriatric problems (Song et al., 2013). Training of medical professionals to understand the specialized needs of the elderly, provision of medical aids, setting up gerontology units, ensuring proper communication with the patients can also be implemented in the primary care policies for effective care (Shrivastava et al., 2013).
Critical Analysis of Independent Nursing Practice Model
Different strategies have been identified that can improve the healthcare service for the elderly. These strategies have been embodied in different care plans globally, which shall be discussed next.
The UK Healthcare Strategic Plan (2015-2020) aims the development of Patient Centered Care, and considers two aspects of improvement: Patient Experience and Strategic cultural alignment. The plan necessitates the involvement of patient experience governance models and strong clinical and administrative leadership. This also requires engagement of medical staff in the process of change, and creates strong cultural alignment (Spurgeon et al., 2015). The plan has 4 stages: stage 1 aims growth in complex care, stage 2 aims to improve partnership network, stage 3 aims to develop value based care and payment and stage 4: incorporates strategic enablers (like a service line operating model, technology, strategy implementation, facility planning and marketing/branding). Different services can be identified that can directly affect a patient’s experience like: inpatient hospitalization and rehab services, skilled nursing facility, outpatient rehabilitation, home care, wellness program, pharmacy support, physicians clinic, diagnostic laboratory, urgent care and ambulatory services. Other factors can influence the services that the patient directly interacts with, and includes: applied analytics, care management team, health management interventions, integrated care, telehealth, informatics and risk stratification, patient engagement and seamless technology (ukhealthcare.uky.edu, 2018).
Figure 1 and 2 above shows how services can be strategically aligned to the needs of the patient, and help to support other services in order to strengthen and improve care through the development of partnership networks. Figure 3 shows how the value of a service model; can be analysed from individual components like the sum quality of care, service, and accessibility to it over the cost of care (ukhealthcare.uky.edu, 2018).
The partnership HealthPlan of California suggests that community based approaches can be developed through an improved access to primary care, improve access to alcohol and drug treatment, developing comprehensive care plan for elderly, supporting the recruitment of providers and commitment to the development of health information exchange and clinical data repository. The plan identifies partnership of 4 pillars (providers, employees, public resources, and community partners) on which a health of individuals can be promoted (Partnershiphp.org, 2018).
Central Health strategic plan incorporates four aspects in the improvement of healthcare model: 1. Improving healthcare through the access of high quality, patient centric coordinated clinical service. 2. Health Promotion through the alignment of health education policies to foster the ability of patients to improve their own health conditions as well as that of their families. 3. Improving health coverage through affordable healthcare products and enrolment to healthcare services that can improve accessibility to care. 4. Developing health infrastructure by ensuring necessary services being in place and accessible by the patient. INP allows all such factors to be considered in the service.
The various aspects identified above can be utilised in the designing of a strategic plan that can improve the healthcare service model of independent nursing practice (centralhealth.net, 2018).
- Keeping the patient’s experience central to the service
- Help in the development of complex care
- Develop partnership network
- Develop value based care
- Using strategic enablers
- Health education
- Improving accessibility to care
- Implementation of health promotion and wellness programs
In the nursing practice, such aspects can be addressed through the development of competencies and skills of the nurse to provide complex and specialized care, which can be catered as per the individual need of each patient. Independent NP can also help to improve accessibility to other healthcare services through referrals and partnerships. Within a home care setting, this can be a very useful strategy as it can ensure the providence of care in the residential setup, and done at the comfort of the patient. Collaboration of care practitioners can also ensure a continuum of uninterrupted care spanning across social support, speciality care, medication management, home health care, care facilities and primary care. The unique specialization of independent nurses allows the providence of care within all these domains. Such viability can be attributed to the adaptability of Independent NP (Onlinenursing.simmons.edu, 2018; nursingmidwiferyboard.gov.au, 2018).
Requirements for Independent Nursing Practice
High quality of healthcare can also be maintained through the improvement of health of the members in aged care center, improving the member experience of care, and also minimizing the cost of maintenance of care. The quality of care can also be improved by addressing the social determinants of health that affects the health of the individuals (Adler et al., 2016). Involving community based programs, and social care workers can help to reduce a sense of isolation experienced by the patients. Furthermore, developing a community and society where the elderly are taken care of by their children or are supported by care workers to ensure the elderly resident’s health needs are properly addressed can be useful methods. The independent nurse can also work in collaboration of other care professionals, sharing health information of the patient, and also ensuring a smooth transition of service, without causing any interruptions to care. Involvement of psychological and medical support can help to identify any early signs of geriatric health problems (health.vic.gov.au, 2018).
Regular visits from Nursing Practitioners to assess the health and well being of the residents in the aged care can allow regular monitoring of the health condition of the patients and also enable early treatment or intervention in case of any significant health risk. Regular visits can also improve patient satisfaction (Forsgärde et al., 2016). Risk assessment can also be suggested to be carried out in the care facility that can help to maintain a safe environment for the residents, and also identify any hazards in the environment. The elderly patients and their families can be educated by the nurses, which can help to develop an understanding of age related problems and co-morbidities and empower the patients and their families to actively participate in the maintenance of well being of the elderly people (Castro ET. Al., 2016).
Collaborative care can be understood as the integrated application of skills, knowledge, attitudes and values that allows working across professions with other healthcare workers, patients, and their families, as well as communities as an when necessary to improve health outcomes. Collaborative care therefore should be able to place the needs of the patient at the centre of collaborative care, maintain commitment to leadership to enable an inter-professional and interpersonal collaboration, foster an equal opportunity that values contributions from each practitioner in the collaborative team, and maintain an effective communication between team members (Valentine et al., 2015). A collaborative approach helps to integrate different specialities like mental and behavioural health, public health, physical therapy and nutrition. Nursing practitioners however is the only profession in this collaboration who has an understanding of the roles of the other professionals in the team. This emphasizes their crucial role in the collaborative care, as they are able to assess clinical. Emotional and social conditions of the patient comprehensively, and utilise available resources to develop a patient cantered plan. Moreover, the adaptability, commitment to goals, empathy and communication skills possessed by the nurses can account for strong leadership and team playing abilities (nursingworld.org, 2018).
Settings for Independent Nursing Practice
Aged healthcare faces a number of challenges that are applicable to health of individuals and it requires cross-sector solutions. The challenges include funding issues, shortage of workforce, usage of technologies and population health planning. Aged care service also helps to reduce unnecessary hospitalizations, and thus reduce load on the local health services, which emphasizes the necessity of collaboration of aged care service with healthcare services. Furthermore, collaboration can ensure the providence of accessible, affordable and quality care for the elderly which can be delivered through sustainable and viable aged care service providers (like residential care for the aged) (Hospitalhealth.com.au, 2018).
Collaboration of service in an aged care facility can be developed over 6 domains: social support, speciality care, primary care, care facility and home health. The social support can be provided through the provision of health literacy, housing, durable devices, meals and transportation facilities for the elderly who cannot afford it. Health literacy can help to improve understanding of health conditions and its risk factors and facilitate proper health seeking behaviour by the mental health patients (Bonabi et al., 2016). This shows how health literacy can encourage patient to seek medical help on time. Provision of housing, durable equipments (like prosthetics and aids), meals and transportation for elderly who are not able to afford the same can ensure that their financial instability is not adversely affecting their health condition. Speciality care can be provided through the collaboration of specialists in surgery, cardiology, oncology, nephrology, dialysis, pain management and transplant services. This can provide support to elderly patient suffering from long term or acute conditions which requires specialist interventions. Home health support can be provided through the providence of medical supplies, home nursing services, sub-acute rehab and home therapies. This can be achieved through specialised nursing services that can offer medical prescription services, as well as rehabilitation or home care services. Moreover, services that are a part of care facilities like long term care, palliative care, primary care and medication can also be provided through independent nursing practices and allied health services. (Shrivastava et al., 2013)
Services in residential care facility can also be improved through the usage of information technology to support clinical staff and improve the flow of information and work process in the care facility. Information technology can be utilized to improve productivity and help in the integration of patient records, foster safe and effective work practice, and also enable proper communication of clinical information across different healthcare domains. Technology can also ensure accuracy and consistency of information flow as the patients move between different care facilities. Thus, such aspects can results in the reduction of time needed by the clinicians and increase productivity (Sydney.edu.au, 2018).
The collaborative process can help in the involvement of multidisciplinary team as well as the patient and their families, with the nurses at the centre of the communication process. Since the nurse is equipped to understand and analyse the roles of each member of the collaboration, they are able to effectively communicate vital information between the team, and furthermore the skills of nurse pertaining to effective communication, and research based practice can further help to collaborate the efforts of the multi disciplinary team (Altman et al., 2018).
Elderly Patient Population for Independent Nursing Practice Model
Different barriers exist in the nursing practice model and can span through different levels: individual, professional, organizational as well as time, cost and system related factors (Fitzgerald et al., 2017; Hain & Fleck, 2014).
Individual barriers include: selection of the ‘right’ person with the required specialization in the right place; challenge to attract experienced NP in aged care service; challenge communicating with different healthcare professionals, patients and their families; competitive salaries offered by public sectors; challenges in covering leave for the nursing practitioner and allotting necessary time needed for professional development and payment of study fee for nursing practitioner service. Communication can be a key skill in overcoming many of these challenges (Arnold & Boggs, 2015). These problems can also be overcome by the demonstration of competency by the NP and their autonomy; exhibiting nursing career development through the role of nursing practitioner; employing NP with excellent clinical skills and interpersonal strengths; involving human resources management that can manage nurses on leave and enable skill development; assisting the NP to integrate clinical competency with critical thinking and management skills.
Professional barriers include: resistance from medical professionals towards NP; involvement of different healthcare professionals from different disciplines for the care of elderly; shortage of time to build a meaningful patient-nurse relationship and develop awareness of NP’s roles; and difficulty in finding mentors for NP (McCarter et al., 2016). These challenges can be overcome through specific strategies which can include: developing credible relation between the nurse and other healthcare professionals; creating a trusting relation; developing meaningful and effective communication; involving an advocate or strategic leader; involving strong mentorship and developing relations with the community.
Organizational barriers can include poor administrative support; structural changes in organization affecting the role of NP; cultural shift experienced by the RN and managers; shortage of time to develop proper clinical governance strategy (Elliott et al., 2016). However, such challenges can be mitigated through the setup of strong governance system; maintaining clarity in the role of NP and defining the scope of support clearly; involving NP with organizational experience; ensuring access to clinical governance procedures and protocols; and providence of organizational resources for the NP (Hain & Fleck, 2014).
Time related barriers can include the shortage of time to meet corporate demands, mismatch between time based funding and the philosophy of holistic care; time needed to learn the organizational processes; time lost in travelling and longer time needed for the treatment or management of complex conditions or co-morbidities.
Cost barriers can include challenges in the coverage of the initial setup as well as ongoing service for NP; availability of sustainable resources to secure income; loss of income due to travelling; covering information technology costs; and lack of support system or referral process. Such challenges can be reduced through the utilization of organizational resources to cover expenses; and using technology and infrastructure efficiently (Hain & Fleck, 2014; McInnes et al., 2015; Health.gov.au 2018).
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