Hamric and Hanson's Advanced Practice Nursing An Integrative Approach EDITION 6

Hamric and Hanson's Advanced Practice Nursing An Integrative Approach EDITION 6 MARY FRAN TRACY, PhD, RN, APRN, CNS, FAAN Associate Professor School of Nursing University of Minnesota Nurse Scientist University of Minnesota Medical Center Minneapolis, Minnesota EILEEN T. O'GRADY, PhD, RN, ANP Certified Nurse Practitioner and Wellness Coach Owner, The School of Wellness McLean, Virginia Table of Contents Cover image Title Page Copyright Dedication Contributors Reviewers Preface Purpose Underlying Premises Organization Audience Approach Transitions References Part I Historical and Developmental Aspects of Advanced Practice Nursing Chapter 1 Highlights From the History of Advanced Practice Nursing in the United States Nurse Anesthetists Nurse-Midwives Clinical Nurse Specialists Nurse Practitioners Conclusion Key Summary Points References Chapter 2 Conceptualizations of Advanced Practice Nursing Nature, Purposes, and Components of Conceptual Models Conceptualizations of Advanced Practice Nursing: Problems and Imperatives Conceptualizations of Advanced Practice Nursing Roles: Organizational Perspectives Conceptualizations of the Nature of Advanced Practice Nursing Models Useful for Advanced Practice Nurses in Their Practice Recommendations and Future Directions Conclusion Key Summary Points References Chapter 3 A Definition of Advanced Practice Nursing Distinguishing Between Specialization and Advanced Practice Nursing Distinguishing Between Advanced Nursing Practice and Advanced Practice Nursing Defining Advanced Practice Nursing Core Definition of Advanced Practice Nursing Seven Core Competencies of Advanced Practice Nursing Differentiating Advanced Practice Roles: Operational Definitions of Advanced Practice Nursing Critical Elements in Managing Advanced Practice Nursing Environments Implications of the Definition of Advanced Practice Nursing Conclusion Key Summary Points References Chapter 4 Role Development of the Advanced Practice Nurse Perspectives on Advanced Practice Nurse Role Development Novice-to-Expert Skill Acquisition Model Role Concepts and Role Development Issues Role Transitions Conclusion Key Summary Points References Chapter 5 Evolving and Innovative Opportunities for Advanced Practice Nursing Patterns in the Evolution of Specialty Nursing Practice to Advanced Practice Nursing Innovative Practice Opportunities (Stage I) Specialties in Transition (Stage II) Emerging Advanced Practice Nursing Specialties (Stage III) Established Advanced Practice Nursing Roles (Stage IV) Conclusion Key Summary Points References Chapter 6 International Development of Advanced Practice Nursing Advanced Practice Nursing Roles Within a Global Health Care Context Facilitating the Introduction and Integration of Advanced Practice Nursing Roles Next Steps in the Global Evolution of Advanced Practice Nursing Roles Conclusion Key Summary Points References Part II Competencies of Advanced Practice Nursing Chapter 7 Direct Clinical Practice Direct Care Versus Indirect Care Activities Six Characteristics of Direct Clinical Care Provided by Advanced Practice Nurses Use of a Holistic Perspective Formation of Therapeutic Partnerships With Patients Expert Clinical Performance Use of Reflective Practice Use of Evidence as a Guide to Practice Diverse Approaches to Health and Illness Management Management of Complex Situations Helping Patients Manage Chronic Illnesses Direct Care and Information Management Conclusion Key Summary Points References Chapter 8 Guidance and Coaching Why Guidance and Coaching? Context of Guidance and Coaching: Definition and Skills Theories and Research Supporting APRN Guidance and Coaching APRN Guidance and Coaching Skills APRN Proficiencies Specific to Coaching APRN Coaching Process The “Four As” of the Coaching Process The Dilemma of Guiding or Leading From Behind Conclusion Key Summary Points References Chapter 9 Consultation Consultation and Advanced Practice Nursing Defining Consultation Model of APRN Consultation Other Models of Consultation Common APRN Consultation Situations Issues in APRN Consultation Conclusion Key Summary Points References Chapter 10 Evidence-Based Practice Evidence-Based Practice and the APRN Evidence and Current Best Evidence: Historical Perspective Steps of the Evidence-Based Process From Policy to Practice: Tips for Achieving Meaningful Changes in Practice Based on Current Best Evidence Future Perspectives Conclusion Key Summary Points References Chapter 11 Leadership The Importance of Leadership for APRNs Leadership: Definitions, Models, and Concepts Types of Leadership for APRNs Characteristics of APRN Leadership Competency Attributes of Effective APRN Leaders Developing Skills as APRN Leaders Developing Leadership in the Health Policy Arena Obstacles to Leadership Development and Effective Leadership Strategies for Implementing the Leadership Competency Conclusion Key Summary Points References Chapter 12 Collaboration Definition of Collaboration Domains of Collaboration in Advanced Practice Nursing Characteristics of Effective Collaboration Impact of Collaboration on Patients and Clinicians Imperatives for Collaboration Context of Collaboration in Contemporary Health Care Processes Associated With Effective Collaboration Implementing Collaboration Strategies for Successful Collaboration Conclusion Key Summary Points References Chapter 13 Ethical Decision Making Foundations of Ethical Practice Characteristics of Ethical Challenges in Nursing Ethical Issues Affecting APRNs Ethical Decision-Making Competency of APRNs Evaluation of the Ethical Decision-Making Competency Barriers to Ethical Practice and Potential Solutions Conclusion Key Summary Points References Part III Advanced Practice Roles: The Operational Definitions of Advanced Practice Nursing Chapter 14 The Clinical Nurse Specialist Overview and Definitions of the Clinical Nurse Specialist Clinical Nurse Specialist Practice: Competencies Within the Spheres of Influence Current Marketplace Forces and Concerns Role Implementation Future Directions Conclusion Key Summary Points References Chapter 15 The Primary Care Nurse Practitioner Current and Historical Perspectives on Primary Care and the Nurse Practitioner Role Primary Care and the Federal Government Practice Redesign in Primary Care Primary Care Workforce and the Context of PCNP Practice Today The Primary Care Nurse Practitioner Future Trends in Primary Care Conclusion Key Summary Points References Chapter 16 The Adult-Gerontology Acute Care Nurse Practitioner Emergence of the Adult-Gerontology ACNP Role Competencies of the Adult-Gerontology ACNP Role Shaping the Scope of Practice for the Adult-Gerontology ACNP Profiles of the Adult-Gerontology ACNP Role and Practice Models Specialization Opportunities Within the Adult-Gerontology ACNP Role Preparation of Adult-Gerontology ACNPs Reimbursement for Adult-Gerontology ACNPs Challenges Specific to the Adult-Gerontology ACNP Role Future Directions Conclusion Key Summary Points References Chapter 17 The Certified Nurse-Midwife Midwife Definitions Historical Perspective The Nurse-Midwifery Profession in the United States Today Implementing Advanced Practice Nursing Competencies Current Practice of Nurse-Midwifery Professional Issues Conclusion Key Summary Points References Chapter 18 The Certified Registered Nurse Anesthetist Brief History of CRNA Education and Practice Profile of the CRNA Current CRNA Practice Role Development and Measures of Clinical Competence Reimbursement Conclusion Key Summary Points References Part IV Critical Elements in Managing Advanced Practice Nursing Environments Chapter 19 Maximizing APRN Power and Influencing Policy Policy: Historic Core Function in Nursing Policy: APRNs and Modern Roles Politics Versus Policy United States Differs From the International Community Key Policy Concepts Policy Models and Frameworks Current Advanced Practice Nursing Policy Issues Emerging Advanced Practice Nursing Policy Issues APRN Political Competence in the Policy Arena Conclusion Key Summary Points References Chapter 20 Marketing and Negotiation Self-Awareness: Finding a Good Fit Choosing Between Entrepreneurship/Intrapreneurship Marketing for the New APRN Negotiation and Renegotiation Overcoming Invisibility Conclusion Key Summary Points References Chapter 21 Reimbursement and Payment for APRN Services Historical Perspective Reimbursement in the United States Commonly Used CPT Codes Medicare Reimbursement Other Reimbursement Models Current and Emerging Reimbursement Issues for APRNs Conclusion Key Summary Points References Chapter 22 Understanding Regulatory, Legal, and Credentialing Requirements The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education Advanced Practice Registered Nurse Master's and Doctoral Education Benchmarks of Advanced Practice Nursing and Education Advanced Practice Registered Nurse Competencies Elements of APRN Regulation and Credentialing Language Associated With the Credentialing of APRNs Scope of Practice for APRNs Standards of Practice and Standards of Care for APRNs Issues Affecting APRN Credentialing and Regulation Influencing the Regulatory Process Current Practice Climate for APRNs Future Regulatory Challenges Facing APRNs Conclusion Key Summary Points References Chapter 23 Integrative Review of APRN Outcomes and Performance Improvement Research Review of Terms Conceptual Models of Care Delivery Impact Evidence to Date “Process as Outcome” Studies Performance (Process) Improvement Activities Disease Management Activities Outcomes Management Activities Impact of APRN Practice Future Directions for Using Outcomes in APRN Practice Conclusion Key Summary Points References Chapter 24 Using Health Care Information Technology to Evaluate and Improve Performance and Patient Outcomes Informatics and Information Technology Supporting Improved Performance and Outcomes Regulatory Reporting Initiatives That Drive Performance Improvement Relevance of Regulatory Reporting to Advanced Practice Nursing Outcomes Foundational Competencies in Managing Health Information Technology Foundational Competencies in Quality Improvement Strategies for Designing Quality Improvement and Outcome Evaluation Plans for Advanced Practice Nursing Conclusion Key Summary Points References Index Copyright 3251 Riverport Lane St. Louis, Missouri 63043 HAMRIC and HANSON'S ADVANCED PRACTICE NURSING:ISBN: 978-0-323-44775-1 AN INTEGRATIVE APPROACH, SIXTH EDITION Copyright © 2019 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2014, 2009, 2005, 2000, and 1996. Library of Congress Cataloging-in-Publication Data Names: Tracy, Mary Fran, editor. | O'Grady, Eileen T., 1963- editor. Title: Hamric and Hanson's advanced practice nursing : an integrative approach / [edited by] Mary Fran Tracy, Eileen T. O'Grady. Other titles: Advanced practice nursing (Hamric) | Advanced practice nursing Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2019] | Preceded by Advanced practice nursing : an integrative approach / [edited by] Ann B. Hamric, Charlene M. Hanson, Mary Fran Tracy, Eileen T. O'Grady. 5th ed. 2014. | Includes bibliographical references and index. Identifiers: LCCN 2017055231 | ISBN 9780323447751 (pbk. : alk. paper) Subjects: | MESH: Advanced Practice Nursing Classification: LCC RT82.8 | NLM WY 128 | DDC 610.73–dc23 LC record available at https://lccn.loc.gov/2017055231 Executive Content Strategist: Lee Henderson Content Development Manager: Lisa Newton Senior Content Development Specialist: Danielle M. Frazier Publishing Services Manager: Julie Eddy Book Production Specialist: Clay Broeker Design Direction: Renee Duenow Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Dedication I would like to dedicate this book to my advanced practice nurse colleagues who are inspirational as they strive every day to provide optimal care for patients. I'm extremely grateful to my family and friends who were a constant source of support throughout the project. MFT I dedicate this book to my beloved profession, to nurses everywhere who care deeply about the human condition, and of course, to my one and only Humayun, who listened patiently to my editing and other woes. Also, to my teenage sons Liam and Conor who keep it real. And funny. EO The editors would also like to dedicate this edition to Ann Hamric and Charlene Hanson. We are grateful for their foresight, their vision, and the passion they convey for the advanced practice nurse role. We are thankful for their previous mentoring and for the consultation they specifically provided for this current edition. Contributors Anne W. Alexandrov PhD, RN, AGACNP-BC, CNS, ANVP-BC, NVRN-BC, CCRN, FAAN Professor College of Nursing University of Tennessee Health Science Center Memphis, Tennessee Professor College of Nursing Australian Catholic University Sydney, Australia NET SMART Health Outcomes Institute Fountain Hills, Arizona Cynthia Arslanian-Engoren PhD, MSN, BSN, FAAN Associate Professor School of Nursing, Department of Health Behavior and Biological Sciences University of Michigan Ann Arbor, Michigan Melissa D. Avery PhD, CNM, FACNM Professor School of Nursing University of Minnesota Minneapolis, Minnesota Denise Bryant-Lukosius BScN, MScN, PhD Associate Professor School of Nursing and Department of Oncology Co-Director Canadian Centre for APN Research McMaster University Clinician Scientist and Director Canadian Centre of Excellence in Oncology APN Juravinksi Hospital and Cancer Centre Hamilton, Canada Karen A. Brykczynski PhD, RN, FNP, FAAN Home Health Nurse Largo, Florida Professor (retired) School of Nursing University of Texas Medical Branch Galveston, Texas Maureen Cahill BSN, MSN, APN-CNS Senior Policy Adviser Regulation National Council of State Boards of Nursing Chicago, Illinois Margaret Faut Callahan CRNA, PhD, FNAP, FAAN Provost Health Sciences Division Loyola University Chicago, Illinois Michael Carter DNSc, DNP University Distinguished Professor College of Nursing University of Tennessee Health Science Center Memphis, Tennessee Adjunct Clinical Professor of Geriatrics College of Medicine University of Arkansas for Medical Sciences Little Rock, Arkansas Adjunct Professor School of Nursing, Midwifery, and Paramedicine Curtin University Perth, Australia Anne Z. Cockerham PhD, CNW, WHNP-BC, CNE Associate Dean for Academic Affairs Frontier Nursing University Hyden, Kentucky Cindi Dabney BSN, MSNA, DNP Assistant Director of Didactic Education Anesthesia Option University of Tennessee Health Science Center Memphis, Tennessee Lynne M. Dunphy PhD, APRN, FNP-BC, FAAN, FAANP Associate Dean for Practice and Community Engagement Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Margaret M. Flinter MSN, PhD Senior Vice President and Clinical Director Community Health Center, Inc. Middletown, Connecticut Mikel Gray PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN Professor Department of Urology and Department of Acute and Specialty Nursing Care School of Nursing University of Virginia Charlottesville, Virginia Jane Guttendorf DNP, CRNP, ACNP-BC, CCRN Assistant Professor School of Nursing, Department of Acute/Tertiary Care University of Pittsburgh Acute Care Nurse Practitioner Department of Critical Care Medicine University of Pittsburgh Medical Center, UPMC Presbyterian Pittsburgh, Pennsylvania Ann B. Hamric PhD, MS, BSN Professor Emeritus School of Nursing Virginia Commonwealth University Richmond, Virginia Charlene M. Hanson EdD, RN, FNP-BC, FAAN Professor Emerita and Family Nurse Practitioner Nursing Georgia Southern University Statesboro, Georgia Gene E. Harkless BSN, MSN, DNSc Associate Professor Nursing University of New Hampshire Durham, New Hampshire Marilyn Hravnak RN, PhD, CRNP, BC, FCCM, FAAC Professor School of Nursing University of Pittsburgh Pittsburgh, Pennsylvania Jean E. Johnson PhD, RN, FAAN Dean Emerita School of Nursing George Washington University Washington, District of Columbia Arlene W. Keeling PhD, RN, FAAN Centennial Distinguished Professor and Associate Director Eleanor Crowder Bjoring Center for Nursing Historical Inquiry School of Nursing University of Virginia Charlottesville, Virginia Ruth M. Kleinpell PhD, RN, APRN-BC, FAAN, FAANP, FCCM Assistant Dean for Clinical Scholarship Professor Vanderbilt University School of Nursing Nashville, Tennessee Professor Rush University College of Nursing Chicago, Illinois Michael J. Kremer PhD, CRNA, CHSE, FNAP, FAAN Professor and Director Nurse Anesthesia Program Rush University College of Nursing Co-Director Rush Center for Clinical Skills and Simulation Rush University Medical Center Chicago, Illinois Brigid Lusk PhD, RN, FAAN Adjunct Clinical Professor College of Nursing University of Illinois at Chicago Chicago, Illinois Carole L. Mackavey DNP, MSN, RN, FNP-C Assistant Professor and Co-Director, FNP Track Family Health/SON University of Texas Health Science Center at Houston Houston, Texas Kathy S. Magdic DNP, ACNP-BC Assistant Professor Acute-Tertiary Care University of Pittsburgh Pittsburgh, Pennsylvania Nancy Munro MN, CCRN, ACNP-BC, FAANP Senior Acute Care Nurse Practitioner Critical Care Medicine Department National Institutes of Health Bethesda, Maryland Eileen T. O'Grady PhD, RN, ANP Certified Nurse Practitioner and Wellness Coach Owner, The School of Wellness McLean, Virginia Geraldine S. Pearson PhD, PMH-CNS, FAAN Associate Professor Psychiatry, Child/Adolescent Division University of Connecticut School of Medicine Farmington, Connecticut Susanne J. Phillips DNP, APRN, FNP-BC Clinical Professor Nursing Science University of California, Irvine Irvine, California Laura Reed MSN, DNP Assistant Professor Advanced Practice and Doctoral Studies University of Tennessee Health Science Center Memphis, Tennessee Melissa A. Saftner PhD, CNM, RN Clinical Associate Professor School of Nursing University of Minnesota Minneapolis, Minnesota Jeanne Salyer PhD, RN Associate Professor Adult Health and Nursing Systems Virginia Commonwealth University School of Nursing Richmond, Virginia Sue Sendelbach PhD, RN, FAAN, FAHA Director of Nursing Research (retired) Abbott Northwestern Hospital Minneapolis, Minnesota Katherine E. Simmonds MS, MPH, WHNP-BC Assistant Professor School of Nursing Track Coordinator of Women's Health and Adult Gerontology/Women's Health NP Specialties MGH Institute of Health Professions Charlestown, Massachusetts Mary Fran Tracy PhD, RN, APRN, CNS, FAAN Associate Professor School of Nursing University of Minnesota Nurse Scientist University of Minnesota Medical Center Minneapolis, Minnesota S. Brian Widmar PhD, RN, ACNP-BC, CCRN, FAANP Director, Adult-Gero Acute Care NP Specialty School of Nursing Vanderbilt University Nashville, Tennessee Marisa L. Wilson DNSc, MHSc, RN-BC, CPHIMS, FAAN Associate Professor and Specialty Track Coordinator Nursing Informatics Family, Community, and Health Systems University of Alabama at Birmingham School of Nursing Birmingham, Alabama Lucia Wocial BA, BS, MS, PhD Nurse Ethicist Fairbanks Center for Medical Ethics Indiana University Health Adjunct Assistant Professor School of Nursing Indiana University Indianapolis, Indiana Frances Kam Yuet Wong BSN, MEd, PhD Professor School of Nursing Hong Kong Polytechnic University Hong Kong, China Reviewers Deborah Becker PhD, ACNP, BC, CHSE, FAAN Practice Associate Professor of Nursing Director, Adult Gerontology Acute Care Nurse Practitioner Program Biobehavioral and Health Science Department University of Pennsylvania, School of Nursing Philadelphia, Pennsylvania Angela P. Clark PhD, RN, ACNS-BC, FAAN, FAHA Associate Professor Emerita School of Nursing University of Texas at Austin Austin, Texas Michelle L. Edwards DNP, APRN, FNP, ACNP, FAANP System Vice President, Advanced Practice National Clinical Enterprise Catholic Health Initiatives Englewood, Colorado Loretta C. Ford EdD, PNP, FAAN, FAANP Professor and Dean Emerita School of Nursing University of Rochester Rochester, New York Lynn Gallagher-Ford PhD, RN, DPFNAP, NE-BC Director Center for Transdisciplinary Evidence-Based Practice College of Nursing Ohio State University Columbus, Ohio Deborah B Gardner PhD, RN, FAAN, FNAP Health Policy and Leadership Consultant Gardner and Associates, LLC Honolulu, Hawaii Laurie K. Glass RN, PhD, FAAN Professor Emerita and Director Center for Nursing History College of Nursing University of Wisconsin—Milwaukee Milwaukee, Wisconsin Ann B. Hamric PhD, RN, FAAN Professor Emeritus School of Nursing Virginia Commonwealth University Richmond, Virginia Charlene M. Hanson EdD, RN, FNP-BC, FAAN Professor Emerita Georgia Southern University Family Nurse Practitioner School of Nursing Georgia Southern University Statesboro, Georgia Catherine Horvath DNP, CRNA Assistant Professor School of Nursing and Health Studies Georgetown University Washington, District of Columbia Lynda A. Mackin PhD, AGPCNP-BC, CCNS Health Science Clinical Professor Physiological Nursing University of California San Francisco School of Nursing San Francisco, California Tim Porter-O'Grady DM, EdD, APRN, FAAN, FACCWS Senior Partner, Health Systems TPOG Associates, Inc. Adjunct Professor, SON Emory University Registered Mediator and Arbitrator Clinical Wound Specialist, Mercy Care Atlanta, Georgia Professor of Practice, CONHI Arizona State University Phoenix, Arizona Professor of Practice and Leadership Scholar, CON Ohio State University Columbus, Ohio Joanne K. Singleton PhD, RN, FNP-BC, CNL, FNAP, FNYAM Professor Graduate Studies College of Health Professions, Lienhard School of Nursing Pace University New York, New York Margaret C. Slota DNP, RN, FAAN Associate Professor; Director, DNP Program School of Nursing and Health Studies Georgetown University Washington, District of Columbia Sheila Cox Sullivan PhD, RN, VHA-CM Director/Research, EBP and Analytics Office of Nursing Services Department of Veterans Affairs Washington, District of Columbia Lisa Summers MSN, DrPH, FACNM Deputy Director DNP Program School of Nursing Yale University New Haven, Connecticut Carol Taylor PhD, RN Professor of Medicine and Nursing Senior Clinical Scholar, Kennedy Institute of Ethics Department of Advanced Nursing Practice Georgetown University School of Nursing and Health Studies Washington, District of Columbia Preface Revision of this sixth edition of Advanced Practice Nursing: An Integrative Approach has provided an opportunity for reflection during this unique time of health care evolution in the United States to see how far advanced practice nursing has come since the first edition of this book by Hamric, Spross, and Hanson in 1996. Editing this book also makes it clear that advanced practice nursing has unbounded opportunities for growth into the future—many of these yet to even be imagined. Advanced practice registered nurses (APRNs) are being seen as increasingly valuable, both inside and outside of nursing. Many events have aligned to contribute to this recognized value of APRNs: the Institute of Medicine's The Future of Nursing report (2010) and its update, Assessing Progress on the IOM Future of Nursing Report (2015); increasing shortages of providers, particularly in underserved areas; increased access to health care created by the Patient Protection and Affordable Care Act (ACA, 2010); a focus on improving and ensuring patient safety and quality care; an aging population with multiple chronic health conditions requiring providers skilled in the coordination of care for these complex patients; a recognition that social circumstances such as education, income level, and access to quality food and water determine health; and an increasing emphasis on preventative health care that goes beyond the provision of medical care alone. The collaboration of APRN professional organizations along with the American Association of Colleges of Nursing and the National Council of State Boards of Nursing to develop the Consensus Model for APRN Regulation (2008) has resulted in APRNs being more cohesive in presenting consistent messaging and speaking with a unified voice. At the time of publication of the previous edition (2014), the Consensus Model was still relatively new. In the time since, APRNs and professional organizations have gained increasing clarity on how to optimize use of the model to promote changes in APRN regulation and standardize APRN educational curricula. As of this writing, APRNs in more than half of the United States have gained full practice authority (National Council of State Boards of Nursing, 2017); yet even in those states, there are still barriers to full practice (e.g., inability to pronounce death, limiting of scope of practice by hospitals and health systems). Further, while the Veterans Administration granted full practice authority to APRNs (United States Department of Veterans Affairs, 2016), they only granted it to three of the four APRN roles, withholding the authority from CRNAs. It is situations like these that highlight the ongoing need for all APRNs to continue to speak with one voice, expressing the value of APRNs as a whole while still recognizing the uniqueness added by each of the APRN roles. The number of Doctor of Nursing Practice (DNP) programs continues to explode, rapidly increasing the number of DNP graduates in the nation's workforce. The DNP-prepared APRN brings a strong set of leadership skills and the expertise to embed evidence into all kinds of practices, which is very beneficial to society. On the other hand, we know the DNP-prepared APRN has created continuing APRN role confusion. Many people inside and outside of nursing confuse the DNP as a new role within nursing versus a degree. This book continues to provide clarity on the four specific APRN roles within the APRN umbrella term, regardless of degree type. As advanced practice education continues to evolve, we would hope the confusion of terms will dissipate. Purpose The purpose of this book is to continue to promote the clarion call for nursing leaders, educators, and practicing clinicians to seek integrated understanding of APRNs. It explores how they are prepared and the evolving opportunities for the roles that they will create and assume given the developing health care landscape. This sixth edition continues to collate the latest trends and evidence regarding APRN competencies, roles, and challenges in today's environment. However, there is still significant work ahead to solidify within and outside the profession the value-added benefit of APRNs as direct care providers and leaders—an imperative for patient safety and quality care around the globe. Underlying Premises Readers may notice a change in terms, with the use of “advanced practice registered nurse” (APRN) in this edition versus “advanced practice nurse” (APN) in previous editions. There were several reasons for this change in terms: (1) APRN is increasingly becoming more common as the standard lexicon within and outside of nursing; (2) to differentiate between the increasingly standardized roles of APRNs in the United States versus the use of the term APN for international roles, which, of necessity, are more varied due to significant differences between countries; and (3) to attempt to provide more clarity between the traditional use of advanced practice nursing for APRN roles versus advanced nursing practice, which is used for all nurses who are obtaining DNP degrees, not just APRNs. Transition to the APRN term should not imply that the editors are viewing these APRN roles only through a regulatory lens. On the contrary, we continue to advocate, as did the previous editors, that advanced practice nursing is viewed in the broadest sense in this book —encompassing the entire professional understanding and enactment of APRN roles, with patients and families at the center of their purpose of existence. It is assumed that health care policy is an ongoing process, made up of small and large revisions over decades. Many health care polices in the United States are being debated and altered, and unintentional consequences are being discovered; therefore, the policy issues surrounding APRNs are, of necessity, living, moving, and everchanging. The purpose of this book is also to make clear the ongoing APRN policy issues in the United States, knowing that incrementalism can make it difficult to write with certitude around any health care policy. Moreover, the international community, who may have a more centralized system, could benefit from knowing about our health policy issues so that they can make strategic decisions on pitfalls to avoid, such as having collaboration legislated. Finally, each APRN student comes to a graduate program with a background in nursing. Human caring and compassion for others lies at the heart of nursing. While caring is not laid out as a core APRN competency, it is assumed that each student who comes to the APRN role already embodies the Nursing Code of Ethics, Provision 1: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (American Nurses Association, 2015). Human caring and showing of compassion are covered in the Direct Clinical Practice and Guidance and Coaching chapters, both more fully and at an advanced practice level. Organization This edition continues the tradition of extensive updating and revision based on the most current evidence available. The editors and authors have incorporated content up until the final feasible moment in order to provide readers with the latest changes in regulatory, credentialing, and professional issues impacting APRNs. Exemplars have been updated throughout the book, and Key Summary Points have been added to the end of each chapter to emphasize the key takeaways for readers. In Part I, “Historical and Developmental Aspects of Advanced Practice Nursing,” Chapter 2 has incorporated new conceptual models, including international models, to continue to provide examples for connecting conceptual models to actual APRN practice. In addition, Chapter 6 has been significantly revised to provide an update on the status of international APN roles and the challenges for the roles in all regions of the world. While advanced practice nursing is significantly different between the United States and other countries, there is much we can do to collaborate and learn from each other. In Part II, “Competencies of Advanced Practice Nursing,” the seven competencies are outlined—Direct Clinical Practice, Guidance and Coaching, Consultation, Evidence-Based Practice, Leadership, Collaboration, and Ethical Decision Making; they continue to stand the test of time as the foundational core for all APRN roles. Chapter 8 has been extensively revised to reflect the increasing importance of APRN guidance and coaching in context of the focus on helping patients and families achieve health. In Part III, “Advanced Practice Roles: The Operational Definitions of Advanced Practice Nursing,” each of the APRN role chapters has been updated to highlight the unique niche APRNs fill in exhibition of the core competencies through each of the specific roles. This is particularly reflected in context of the implications of the Consensus Model, the changing health care policy environment, and increasing numbers of DNP-prepared APRNs. Of note in Part IV, “Critical Elements in Managing Advanced Practice Nursing Environments,” Chapter 19 has been revised to provide an overall context of policy implications for APRNs and the need for APRNs to be engaged in advocacy at all levels. Chapter 20 includes more information on entrepreneurship and intrapreneurship. Chapter 23 continues to be a rich resource for evidence demonstrating the outcomes of APRNs. Audience This book is intended for graduate nursing students, practicing APRNs, educators, administrators, and nursing leaders. The book will be a resource for graduate students as they learn to incorporate theory, research, policy, and practice skills into their developing roles. It provides an understanding of the common threads among APRN roles, the unique contributions of each role, and the holistic advanced skills distinct to APRNs as compared with other non-nurse providers. This book will be useful to practicing APRNs as an update for a health care environment that is constantly changing. It provides a foundation for practice and an opportunity to self-assess for areas of strength and areas for growth throughout one's APRN career. APRNs can use pertinent sections of the book with administrators to highlight role functions and documented outcomes of APRNs and how optimization of each role can be envisioned and implemented. For educators, the book continues to serve as a comprehensive resource for use in educational APRN program curricula. Instructor resources available with this book include slides with content that corresponds to each chapter as well as each of the images in the book. In addition, a new instructor resource with this edition will be a test bank of questions. These Evolve resources can be accessed at http://evolve.elsevier.com/Hamric/ Approach The Editors extend a sincere and grateful thank you to the book's contributors. It has been an even more challenging endeavor to complete this sixth edition revision during these chaotic and uncertain times in the US health care environment. It, at times, seems as if the focus of health care legislation and policy is changing on a daily basis. It has taken thoughtful consideration on the part of each author to determine how to update the chapters with meaningful detail, while still conveying the key points for the current and future practice of APRNs, notwithstanding the exact contextual changes that are yet unknown. Regardless of the eventual result of US health care policy and enactment, quality and holistic patient care will always be the focus of APRN practice. APRNs are here to stay, and bringing all APRNs under the same umbrella is a powerful way to strengthen our ability to write our own script. The strength of the wolf is in the pack. Transitions In closing, it is with deep gratitude that we want to acknowledge the transition in editors with this edition. The fifth edition was Ann Hamric's last as the senior editor of this text. Ann writes: “In both its rewards and challenges, envisioning and ‘birthing’ the first five editions of this book has been a highlight of my professional career. When we began this enterprise, the profession had not agreed on educational or certification requirements to be considered an APN, or whether APNs needed to maintain a direct clinical practice. There was no integrative understanding that advanced practice nursing included midwifery or nurse anesthesia. Now, all these features of advanced practice nursing are well established. Watching the international growth of advanced practice nursing and interacting with international colleagues who are using this work to advance practice in their own countries has been very gratifying. I am deeply indebted to the other editors and all our contributors over the editions for the joy of creating a work that has stood the test of time and provided leadership for understanding this critically important level of nursing practice. Many of those who wrote with us in the various editions have become personal friends as well as valued colleagues. This work has immeasurably enriched my life on many levels, and I am very grateful to have had a part in shaping advanced nursing through this book.” Charlene Hanson has also retired as editor for the book while continuing in a mentoring and support role. Chuckie writes, ”When I came to the new conceptualization for this textbook in 1993, it was with the idea that as an editor I would help to integrate the APN roles of nurse practitioner, nurse midwife, and nurse anesthetist into the seminal CNS work of Hamric and Spross. It has been a fine journey, with rich rewards, working through exciting and challenging times with wonderful colleagues. I have watched health care and advanced practice nursing significantly advance with each new edition, fondly known by students as ‘The Hamric Book.’ Helping graduate students here and abroad to find their niche as competent, resourceful APNs has been a high point of my career. My heartfelt thanks to all who have made this journey possible for me. I look forward to seeing where we are headed in the future.” Mary Fran Tracy Eileen T. O'Grady References American Nurses Association. Code of ethics for nurses with interpretive statements. Author: Silver Spring, MD; 2015. APRN Joint Dialogue Group. Consensus model for APRN regulation: Licensure, accreditation, certification & education. [Retrieved from] http://www.aacn.nche.edu/educationresources/APRNReport.pdf; 2008. Institute of Medicine. The future of nursing: Leading change, advancing health. National Academies Press: Washington, DC; 2011. Institute of Medicine. Report in brief: Assessing progress on the Institute of Medicine report. [The Future of Nursing; Retrieved from] http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/20 Report-in-brief.pdf; 2015. National Council of State Boards of Nursing. Implementation status map. [Retrieved from] https://www.ncsbn.org/5397.htm; 2017. Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010). United States Department of Veterans Affairs. VA grants full practice authority to advance practice registered nurses. [Retrieved from] https://www.va.gov/opa/pressrel/pressrelease.cfm? id=2847; 2016. PA R T I Historical and Developmental Aspects of Advanced Practice Nursing OUTLINE Chapter 1 Highlights From the History of Advanced Practice Nursing in the United States Chapter 2 Conceptualizations of Advanced Practice Nursing Chapter 3 A Definition of Advanced Practice Nursing Chapter 4 Role Development of the Advanced Practice Nurse Chapter 5 Evolving and Innovative Opportunities for Advanced Practice Nursing Chapter 6 International Development of Advanced Practice Nursing CHAPTER 1 Highlights From the History of Advanced Practice Nursing in the United States Brigid Lusk, Anne Z. Cockerham, Arlene W. Keeling “You measure the size of the accomplishment by the obstacles you had to overcome to reach your goals.” —Booker T. Washington CHAPTER CONTENTS Nurse Anesthetists, 2 Anesthesia at Mayo Clinic, 3 Early Challenges, 4 Growth of Nurse Anesthesia Practice, 4 Reimbursement and Education, 6 Nurse-Midwives, 7 “Granny Midwives,” 7 Frontier Nursing Service Midwives, 7 Nurse-Midwifery: Early Education and Organization, 7 Growth of Midwifery Practice, 8 Reimbursement, 9 Nurse-Midwifery: Later Education, 10 Clinical Nurse Specialists, 10 Psychiatric Nursing Specialists, 10 Coronary Care Nursing Specialists, 11 Growth of Clinical Nurse Specialist Practice, 11 Declining Demand for Clinical Nurse Specialists, 13 Clinical Nurse Specialist Education and Reimbursement, 14 Nurse Practitioners, 15 The Henry Street Settlement and Primary Care, 15 The Frontier Nursing Service and Other Examples of Early Primary Care, 16 Growth of Nurse Practitioner Practice, 17 Controversy and Support for the Nurse Practitioner's Role, 19 Growth in Nurse Practitioner Numbers and Expanded Scope of Practice, 20 Neonatal and Acute Care Nurse Practitioners, 21 Nurse Practitioner Education, 22 Conclusion, 22 Key Summary Points, 24 This chapter sets the stage for the rest of the book. Nurses who ventured into advanced practice roles in the years before certification and accreditation and legislation need to have their stories told. More than that, these stories provide continuity to guide us through to our current practice and provide a basis for our current thinking. Awareness of the history of advanced practice nursing is a necessary foundation for effecting changes in practice and policy. Fortunately, these stories also make for fascinating reading. This chapter covers selected highlights of the history of advanced practice nursing in the United States from the late 19th century to the present (Box 1.1). It examines four established advanced practice roles —certified registered nurse anesthetists (CRNAs), certified nursemidwives (CNMs), clinical nurse specialists (CNSs), and nurse practitioners (NPs)—in the context of the social, political, and economic environment of the time and within the context of the history of medicine, technology, and science. Legal issues and issues related to gender and health care workforce are considered. Although sociopolitical and economic context is critical to understanding nursing history, only historical events specifically relevant to the history of advanced practice nursing are included. Readers may consult the references of this chapter for further information. Box 1.1 Timeline 1915 Lakeside Hospital School of Anesthesia opens in Cleveland, Ohio 1925 Kentucky Committee for Mothers and Babies, precursor to Frontier Nursing Service, founded 1931 American Association of Nurse Anesthetists (AANA) founded 1941 American Association of Nurse-Midwives (AANM) founded 1945 AANA develops and implements Certified Registered Nurse Anesthetists certification examination 1954 Master's Program in Psychiatric Nursing started at Rutgers University—first Clinical Nurse Specialist education program 1955 American College of Nurse-Midwives (ACNM) founded 1965 Pediatric Nurse Practitioner certification program opens in Colorado 1969 Merger of ACNM and AANM 1973 National Association of Pediatric Nurse Practitioners founded 1984 All states recognize nurse-midwifery 1985 American Academy of Nurse Practitioners (AANP) founded 1995 National Association of Clinical Nurse Specialists founded 1995 American College of Nurse Practitioners (ACNP) founded 2002 Acute Care Nurse Practitioners join the AANP 2004 American Association of Colleges of Nursing recommends that all advanced practice nurses earn Doctor of Nursing Practice degree 2013 American Association of Nurse Practitioners founded through merger of AANP and ACNP The Doctor of Nursing Practice (DNP) degree, introduced by the American Association of Colleges of Nursing (AACN) in 2004, was aimed at ensuring a strong educational preparation for advanced practice registered nurses (APRNs). Initially, this initiative was developed in response to the reality of ever-increasing curricular requirements in master's degree programs throughout the country (Keeling, Kirchgessner, & Brodie, 2010). As originally proposed by the AACN (2014), the DNP would standardize practice entry requirements for all APRNs by the year 2015, assuring the public that each APRN would have had 1000 supervised clinical hours prior to entering the practice setting. Moreover, the proposed curriculum for DNPs would include competencies deemed essential for nursing practice in the 21st century (AACN, 2006). The year 2015 has now come and gone but the issue of requiring the practice doctorate remains unsettled. Discussion surrounding the DNP as assessed by each of the four major APRN professional bodies is covered at the end of each section of this chapter. A brief comment on terminology: The use of the term specialist in nursing can be traced to the turn of the 20th century, when it was used to designate a nurse who had completed a postgraduate course in a clinical specialty area or who had extensive experience and expertise in a particular clinical practice area. With the introduction of the NP role during the 1960s and 1970s, the terms expanded role and extended role were used, implying a horizontal movement to encompass expertise from medicine and other disciplines. The more contemporary term advanced practice, which began to be used in the United States in the 1980s, reflects a more vertical or hierarchical movement encompassing graduate education within nursing, rather than a simple expansion of expertise by the development of knowledge and skills used by other disciplines. Since the 1980s, the term advanced practice nurse (APN) has increasingly been used to delineate CRNAs, CNMs, CNSs, and NPs. In the last decade, state nurse practice acts have gradually adopted the term advanced practice registered nurse. These professional and regulatory influences served to unite the advanced practice specialty roles conceptually and legislatively, thereby promoting collaboration and cohesion among APRNs. Nurse Anesthetists The roots of nurse anesthesia in the United States can be traced to the late 19th century, shortly after the use of certain gasses to induce unconsciousness was discovered. Thatcher (1953) cited contemporary accounts of two instances of nurses giving anesthesia as early as the American Civil War (1861–1865). In 1863, following the Battle of Gettysburg, a Mrs. John Harris set out from Baltimore with “chloroform and stimulants” and ministered “as much as in her power to the stream of wounded” (Moore, 1866; cited in Thatcher, 1953, p. 33). In the second instance, taken from The Medical and Surgical History of the War of the Rebellion (1883): “More chloroform was added and reapplied by a nurse in attendance (the surgeon having stepped aside for a moment)” (Thatcher, 1953, p. 34). Jolly, in her history of Roman Catholic nuns during the same war, cited further instances of nuns administering anesthesia (Jolly, 1927). The administration of chloroform was a relatively simple procedure in which the anesthetizer poured the drug over a cloth held over the patient's nose and mouth; several early nursing texts included instructions for anesthetic administration (Box 1.2). However, one of these, Nicholas Senn's A Nurse's Guide to the Operating Room, gave a real sense of the hazards involved. He wrote: Box 1.2 Instructions for Administration of Chloroform (1893) A nurse is often called upon in private practice to administer an anæsthetic, as it is not possible at every operation to have sufficient medical assistance. (p. 331) … The forenoon is the best time to select for giving an anæsthetic, as the vital powers are in better condition, if the patient has had a good night and is not exhausted by nervous strain, pain, or work. The clothing should be light and warm, but loose about the neck and chest, and no corset or tight waist should be permitted, because the respiratory organs must have freedom of movement. … If the patient be a child, care should be taken to see that the mouth is quite empty, as there may be coins, buttons, or other articles stowed away in the mouth. (pp. 332–333) … The nurse must also have at hand a hypodermic syringe (sterilized and in good order), whiskey or brandy, tincture of digitalis, a solution of strychnine, morphine, atropine, and aqua ammonia, as any of them may be called for. (p. 333) … Besides the anæsthetizer, if the patient is a woman, the nurse should always be present to give any necessary assistance, but a second or even a third person may be needed if there be much struggling. (p. 334) Ether is probably given in this country oftener than any other anæsthetic, as there seems to be little danger to life under ordinary circumstances when it is carefully administered. … Speaking generally, chloroform is preferable for very young or very old patients. (p. 334) … In the early stages of the administration of ether the patient may suddenly stop breathing and the face become cyanosed; the cone should be at once removed, and pressure made upon the chest and sides once or twice, when the breathing will recommence. (p. 336) From Adams Hampton, I. (1893). The administration of anæsthetics. In Nursing: Its principles and practice (Ch. 22, pp. 331–336). Philadelphia: Saunders. Usually complete anesthesia is preceded by a stage of excitement of variable duration. … The patient shouts, prays, swears, sings, cries, laughs, or fights, according to his temperament, habits, religious belief, occupation or social position in life. Tonic and clonic spasms, irregular respiration and cyanosis are some of the alarming symptoms. (Senn, 1905, p. 90) Yet nurses typically gave anesthesia only when a physician was unavailable. This was very likely when surgery was performed in private houses, when a nurse could well be the only other trained person present (Adams Hampton, 1893; Senn, 1905; Weeks-Shaw, 1902). Following the increasingly scientific and specialized nature of giving anesthesia, the practice became the prerogative of physicians, although there arose notable exceptions. Anesthesia at Mayo Clinic At St. Mary's Hospital in Rochester, Minnesota, Dr. William Worrall Mayo was among the first physicians in the country to recognize and formally train nurse anesthetists. In 1889, Mayo hired Edith Granham to be his anesthetist and office nurse. Subsequently, he hired Alice Magaw (later referred to as the “mother of anesthesia”; Keeling, 2007). Magaw kept excellent records of her results and, in 1900, published them in the St. Paul's Medical Journal. Reporting her “Observations on 1,092 Cases of Anesthesia from January 1, 1899 to January 1, 1900,” she wrote: In that time, we administered an anesthetic 1,092 times; ether alone 674 times; chloroform 245 times; ether and chloroform combined, 173 times. I can report that out of this number, 1,092 cases, we have not had an accident; we have not had occasion to use artificial respiration once; nor one case of ether pneumonia; neither have we had any serious renal results. Tongue forceps were used but once, the operation was on the jaw and it was quite necessary. (Magaw, 1900, p. 306) Between 1899 and 1901, the family of Doctors Mayo added several other nurse anesthetists to their surgical teams. Soon, the Mayo Clinic would become world renowned for its nurse anesthesia training program. Early Challenges During the 1910s, nurse anesthetists faced obstacles as well as new opportunities. Early in the decade, as the specialty of anesthesia was on the rise, the medical profession began to question a nurse's right to administer anesthesia, claiming that these nurses were practicing medicine without a license. In 1911, the New York State Medical Society argued (unsuccessfully) that the administration of an anesthetic by a nurse violated state law (Thatcher, 1953). A year later, the Ohio State Medical Board passed a resolution specifying that only physicians could administer anesthesia. Despite this resolution, nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio, in 1915. The challenge culminated in a lawsuit brought against the Lakeside Hospital program by the state medical society. This lawsuit was unsuccessful and resulted in an amendment to the Ohio Medical Practice Act protecting the practice of nurse anesthesia. However, medical opposition to the practice of nurse anesthesia continued in Kentucky, and another lawsuit against nurse anesthetists was filed (Frank et al. v. South et al., 1917). In that case, the Kentucky appellate court ruled that anesthesia provided by nurse anesthetist Margaret Hatfield did not constitute the practice of medicine if it was given under the orders and supervision of a licensed physician (in this case, Dr. Louis Frank). The significance of this decision was that the courts declared nurse anesthesia legal but “subordinate” to the medical profession. It was a landmark decision, one that would have lasting implications for nurse anesthetists' practice. Later in the century it would also have an impact on the practice of APRNs in all four roles (Keeling, 2007). Growth of Nurse Anesthesia Practice Opportunities for nurse anesthetists increased, albeit poignantly, when the United States entered World War I in 1917. That year more than 1000 nurses were deployed to Britain and France, including nurse anesthetists, some of whom had trained at the Mayo and Cleveland Clinics. The realities of the front were gruesome; shrapnel created devastating wounds and mustard gas destroyed lungs and caused profound burns (Beeber, 1990). The resulting need for pain relief and anesthesia care for the wounded soldiers created an immediate demand for nurse anesthetists' knowledge and skills (Keeling, 2007). The war also created opportunities for research, and physicians and nurses began investigating new methods of administering anesthesia. At the well-established Lakeside Hospital anesthesia program, Dr. George Crile and nurse anesthetist Agatha Hodgins experimented with combined nitrous oxide–oxygen administration. They also investigated the use of morphine and scopolamine as adjuncts to anesthesia. After the war, opportunities for the employment of nurse anesthetists were mixed. For example, in 1922 Samuel Harvey, a Yale professor of surgery, hired Alice M. Hunt as an instructor of anesthesia with university rank at the Yale Medical School, a significant and prestigious appointment for a nurse (Thatcher, 1953). In contrast to Hunt's experience, however, many other nurse anesthetists struggled to find practice opportunities. Medicine was becoming increasingly complex, scientific, and controlled by organized medical specialties intent on preserving their spheres of practice, including anesthesia. Interprofessional conflict over disciplinary boundaries seemed inescapable. It was soon clear that nurse anesthetists, too, needed to organize as a specialty. In 1931, at Lakeside Hospital, Hodgins established the National Association of Nurse Anesthetists (later renamed the American Association of Nurse Anesthetists [AANA]) and served as the organization's first president. At the first meeting of the association, the group voted to affiliate with the American Nurses Association (ANA). However, the ANA denied the request, probably because the ANA was afraid to assume legal responsibility for a group that could be charged with practicing medicine without a license (Thatcher, 1953). The ANA's fears were not unfounded. During the 1930s, the devastation of the national economy made jobs scarce and the tension between nurse anesthetists and their physician counterparts continued, with more legal challenges to the practice of nurse anesthesia. In California, the Los Angeles County Medical Association sued nurse anesthetist Dagmar Nelson in 1934 for practicing medicine without a license; Nelson won. According to the judge, “The administration of general anesthetics by the defendant Dagmar A. Nelson, pursuant to the directions and supervision of duly licensed physicians and surgeons, as shown by the evidence in this case, does not constitute the practice of medicine or surgery” (McGarrel, 1934). In response, Dr. William Chalmers-Frances filed another suit against Nelson that again resulted in a judgment for Nelson (ChalmersFrances v. Nelson, 1936). In 1938, the physician appealed the case to the California Supreme Court, which again ruled in favor of Nelson. The case became famous. The courts established legal precedent—the practice of nurse anesthesia was legal and within the scope of nursing practice, as long as it was done under the guidance of a supervising physician. At that time there were 39 training programs for nurse anesthetists in the nation (Horton, 2007a). While World War II provided opportunities for young nurses in Europe to learn the skills necessary to administer anesthesia, it also was the period in which anesthesia grew into a medical specialty (Waisel, 2001). In 1939, just before the United States entered the war, the first written examination for board certification in medical anesthesiology was given, but the specialty still sought legitimacy. Meanwhile, demands for anesthetists, advances in the types of anesthesia available, and continuing education in the field increasingly stimulated physicians' interest in the specialty. In particular, the use of the new drug sodium pentothal required specialized knowledge of physiology and pharmacology, underscoring the emerging view that only physicians could provide anesthesia. In fact, the administration of anesthesia was becoming more complex, and anesthesiologists demonstrated their expertise not only in administering sodium pentothal but also in performing endotracheal intubation and regional blocks (Waisel, 2001). Clearly, medicine was strengthening its hold on the specialty. At the same time, World War II increased the demand for anesthetists on the battlefield. Despite profound shortages of anesthetists early in the war, the US military would not grant nurse anesthetists a specific designation within the military, and experienced nurse anesthetists were required to accept general nurse status. Later, when shortages became even more severe, staff nurses were trained to administer anesthesia (Exemplar 1.1). Exemplar 1.1 Nurse Anesthetists in the 8th Evacuation Hospital, Italy, 1942–1945 (Courtesy University of Virginia, Center for Nursing Historical Inquiry.) During World War II, the University of Virginia sponsored the 8th Evacuation Hospital, a 750-bed mobile hospital a few miles from the front lines in North Africa and Italy. Conditions were demanding and the work overwhelming; surgical teams sometimes operated around the clock despite air raids, heavy rains, and blackouts. There, Dorothy Sandridge Gloor, a young surgical nurse, was trained on the job to give anesthesia. The unit had only one trained anesthesiologist and two nurse anesthetists on staff, and it soon became apparent that more help was needed if the team was to keep up with the “endless stream of battle casualties requiring surgery” (Kinser, 2011, p. 11). Gloor and other nurse anesthetists worked side by side with the surgeons for 16-hour shifts, collaborating with their colleagues to save the injured soldiers. She learned new skills and the specialty knowledge necessary to deliver anesthesia, noting how she learned to start intravenous infusions and make critical observations of the patient on which to base the administration of anesthesia (Kinser, 2011). Working with patients to calm their fears prior to surgery, and explaining what would happen in the operating suite, Gloor and her colleagues demonstrated expertise in coaching the critically injured men. Shortly afterward the United States was again at war, this time with Korea, and once again war provided a setting in which opportunities abounded for nurse anesthetists. By the end of the decade, the army had established nurse anesthesia education programs, including one at Walter Reed General Hospital, which graduated its first class in 1961—but this class consisted only of men. Later, the Letterman General Hospital School of Anesthesia in San Francisco also graduated an all-male class. This significant movement of men into a nursing specialty was unprecedented and would continue in the next decade when the United States entered the war in Vietnam. As was the case in wars of other eras, the war in Vietnam (1955– 1975) provided nurses with opportunities to stretch the boundaries of the discipline as they treated thousands of casualties in evacuation hospitals and aboard hospital ships. Not surprisingly, nurse anesthetists played an active role at the front, providing vital services in the prompt surgical treatment of the wounded. According to one account: The nurse anesthetist suddenly became a part of a new concept in the treatment of the severely wounded. The Dust-Off helicopter brings medical aid to severely wounded casualties who formerly would have died before or perhaps during evacuation. … Very often it is a nurse anesthetist who first is available to intubate a casualty, and by so doing may avoid the need for tracheostomy. (Jenicek, 1967, p. 348) Opportunity was not without cost. Of the 10 nurses killed in Vietnam, two were nurse anesthetists (Bankert, 1989). Reimbursement and Education Reimbursement for CRNA practice is not clear cut. In fact, third-party payment had its own set of issues. Beginning in 1977, the AANA led a long and complex effort to secure third-party reimbursement under Medicare so that CRNAs could bill for their services. The organization would finally succeed in 1989. Meanwhile, the financial threat posed by CRNAs to physicians was the source of continued interprofessional conflicts with medicine. During the second half of the 20th century, tensions escalated, particularly in relation to malpractice policies, antitrust, and restraint of trade issues. In 1986, Oltz v. St. Peter's Community Hospital established the right of CRNAs to sue for anticompetitive damages when anesthesiologists conspired to restrict practice privileges. A second case, Bhan v. NME Hospitals, Inc., et al. (1985), established the right of CRNAs to be awarded damages when exclusive contracts were made between hospitals and physician anesthesiologists. Undeniably, CRNAs were winning the legal battles and overcoming practice barriers erected by hospital administrators and physicians. Since the founding of the AANA in the early 1930s, the primary focus had been to improve educational standards. The leaders had stressed university affiliation and a standardized curriculum. The AANA's Essentials of an Acceptable School of Anesthesiology for Graduate Registered Nurses first came out in 1945. At the same time the AANA instituted mandatory certification for CRNAs. This formal credentialing of CRNAs specified the requirements that a nurse had to meet to practice as a nurse anesthetist, preceded credentialing of nurses in the other specialties, and marked a significant milestone. Five years later the AANA's plan for accreditation of anesthesia programs was approved, and the first accreditation of programs started in 1952 (Horton, 2007a). The 1970s proved to be a difficult decade for nurse anesthetists. In 1972, years after the inception of nurse anesthesia as a specialty role, only four state practice acts specifically mentioned them. Nevertheless, some progress was made in interprofessional relations that year. The AANA and the American Society of Anesthesiologists issued a “Joint Statement on Anesthesia Practice,” promoting the concept of the anesthesia team. However, in 1976 the Board of Directors of the American Society of Anesthesiologists voted to withdraw support from the 1972 statement, endorsing one that explicitly supported physician control over CRNA practice (Bankert, 1989). Meanwhile, the AANA continued to promote university affiliation, and by 1982 the AANA President and Board of Directors promoted the baccalaureate degree as an entry requirement for nurses entering anesthesia programs and master's degrees for graduates (Horton, 2007b). The 1990s saw a significant growth in CRNA education programs, although many of the programs were very small. As the decade opened, there were 17 master's programs in nurse anesthesia; by 1999, there were 82 (Bigbee & Amidi-Nouri, 2000). In 2017, there are 120 accredited nurse anesthesia programs in the United States; 62 are approved to award a doctoral degree (AANA, 2017). Since 1998, all accredited programs in nurse anesthesia are required to be at the master's level (Horton, 2007b); however, they are not uniformly located in schools of nursing. Instead, they are housed in a variety of disciplines, including schools of nursing, medicine, allied health, and basic science. The University of Minnesota started the first postbaccalaureate DNP program for CRNAs in 2009 (Glass, 2009). Following up on the AANA's long pursuit of education reflective of the complexities of modern anesthesia delivery, plans are in place for a clinical doctorate as entry to nurse anesthesia practice. In 2007, the AANA affirmed its support that the Doctor of Nurse Anesthesia Practice (DNAP) be the entry for nurse anesthesia practice by 2025 (AANA, 2007). Seven years later the Council on Accreditation for Nurse Anesthesia Programs approved trial standards for a practice doctorate for implementation in 2015. All students entering nurse anesthesia programs in and after 2022 must graduate with a doctoral degree (Council, 2015). Chapter 18 presents a discussion of the current CRNA role. Nurse-Midwives Unlike nurse anesthetists, who have only been practicing for 150 years or so, midwives have practiced since the beginning of time. Midwives entered the US through the slave trade or during waves of European immigration. These untrained or foreign-trained women lost much of the public's esteem as childbirth became medicalized in the late 19th and early 20th centuries. As Clara Noyes, an early nurse leader, wrote “the word ‘midwife,’ in America, at least, is one to which considerable odium is attached, and immediately creates a mental picture of illiteracy, carelessness and general filth” (Noyes, 1912, p. 466). With the rise of scientific medicine, coupled with the possibility of “twilight sleep” (through scopolamine and morphine), many upper and middle class urban white women began to use obstetricians to deliver their babies in hospital delivery rooms (Dawley, 2000; Rinker, 2000). Meanwhile, women in isolated communities throughout the country, particularly in rural settings, continued to rely on lay midwives well into the 20th century. “Granny Midwives” Granny midwives, as they were condescendingly called, were untrained African-American women who provided the vast majority of obstetric care in the racially segregated southern US states prior to the 1950s. Typically they were the only providers of care for most black Southern women at a time when few hospitals admitted black patients and there was no public funding to support physician attendance in the home. In rural southern states such as Mississippi, in which 50% of the population was black, most women (80% of AfricanAmerican and 8% of white women) relied on these midwives to deliver their babies (Smith, 1994). In 1940s Arkansas, granny midwives attended approximately three fourths of all AfricanAmerican births (Bell, 1993). Yet data from 1921 actually showed that the physicians' outcomes were no better than those of the lay midwives (Dawley, 2000). Frontier Nursing Service Midwives In 1925, nurse-midwife Mary Breckinridge founded the Frontier Nursing Service (FNS) in an economically depressed, rural mountainous area of southeastern Kentucky. British nurse-midwives and American public health nurses provided midwifery and nursing care through a decentralized network of nurse-run clinics (Breckinridge, 1981; Rooks, 1997). Because there were few roads in the mountainous region, the nurses traveled by horseback to attend births, carrying their supplies in saddlebags. One FNS nurse described the bags and their standing orders, or Medical Routines, whereby a physician committee supervised their practice: The whole of the district work of the FNS in the Kentucky mountains is done with the aid of two pairs of saddle-bags. … In these bags we have everything needed for a home delivery. … In one of the pockets we carry our Medical Routines which tells us what we may—and may not—do. A very treasured possession! (Summers, 1938, pp. 1183– 1184) Nurse-Midwifery: Early Education and Organization In the early 20th century, national concern about high maternal-infant mortality rates led to heated debates surrounding issues of midwife licensure and control, and lay midwives were blamed. In 1914, Dr. Frederick Taussig, speaking at the annual meeting of the National Organization for Public Health Nursing (NOPHN) in St. Louis, proposed that the creation of “nurse-midwives” might solve the “midwife question” and suggested that nurse-midwifery schools be established to train graduate nurses (Taussig, 1914). Later in the decade, the Children's Bureau called for efforts to instruct pregnant women in nutrition and recommended that public health nurses teach principles of hygiene and prenatal care to so-called granny midwives (Rooks, 1997). Aside from two tiny, short-lived nurse-midwifery schools (Manhattan Midwifery School in New York City and Preston Retreat Hospital in Philadelphia), about which little is documented, the earliest school to educate nurse-midwives was the School of the Association for the Promotion and Standardization of Midwifery (APSM) in New York City (Burst & Thompson, 2003). Affiliated with the Maternity Center Association, the APSM opened in 1932. More commonly known as the Lobenstine Midwifery School, the APSM graduated its first class in 1933. In 1939, the entry of Britain into World War II proved to be the catalyst for the establishment of the second major school for nurse-midwifery in the United States. That year, the Kentucky FNS lost many of its British nurse-midwives when they returned to England to work; in response, FNS leader Mary Breckinridge established the Frontier Graduate School of Midwifery (Buck, 1940; Cockerham & Keeling, 2012).a A short-lived midwifery school, the Tuskegee School of Nurse-Midwifery, was opened in Alabama for African-American nurses and lasted from 1941 to 1946 (Exemplar 1.2). The aim was to reduce the high infant and maternal mortality in the southern US, but the school closed due to untenable working conditions leading to an inability to retain instructors (Varney & Thompson, 2016). Exemplar 1.2 Nurse-Midwife Maude Callen Maude Callen (1898–1990) was unknown outside her small South Carolina community until photojournalist W. Eugene Smith produced a 10-page photo essay on her for Life Magazine in December 1951. Callen's remarkable work as a nurse-midwife made a national impression. Two years later, in a follow-up article, the magazine wrote that readers had donated $18,500—enough to build a much-needed clinic. Callen trained as a nurse at the Georgia Infirmary, the first hospital for African-Americans in the United States and one of the earliest to train African-American women as nurses. Callen and her husband then moved to Pineville, South Carolina, where Callen had accepted an appointment as a missionary nurse. Historian Darlene Clark Hine quoted a newspaper report: “Pineville was [twenty-two] miles from the nearest hospital or [ten miles to the local] doctor and people sent for Miss Maude when they became ill. She was available day and night” (2011, p. 133). During her first years in Pineville, after she was hired as a public health nurse, Callen organized public health clinics, conducted prenatal classes, opened the county's first venereal disease clinic, and vaccinated children in schools. One former student gives a vivid picture of Callen as he remembered those days: “She came in to give us shots and we were afraid; there was a lot of running and hollering in the classroom. But she held us and did her job. She would dress so neat. She wore a gray uniform with a white collar and white shoes. She was a beautiful lady” (quoted in Clark Hine, 2011, p. 135). With support from the state division of maternal and child health, Callen attended the 6-month midwifery course offered by the Tuskegee School of Nurse-Midwifery in Alabama (Clark Hine, 2011). As the first African-American nurse-midwife in South Carolina, Callen taught annual midwifery institutes, was called out to assist with difficult births, and delivered more than 800 babies. A midwifery student remembered “I don't know what would have happened [to the people] if Miss Maude had not been there” (quoted in Clark Hine, 2011, p. 135). The establishment of a formal organization of practicing nursemidwives, the American Association of Nurse-Midwives (AANM), was key to midwifery development in the 1940s. The AANM was incorporated in 1941 under the leadership of Mary Breckinridge (News Here and There, 1942, p. 832). Three years later, in 1944, the NOPHN established a section for nurse-midwives within their organization. However, there were organizational issues for the midwives when the NOPHN was absorbed by the two other major nursing organizations in the early 1950s. The American College of Nurse-Midwives (ACNM) was founded in 1955. In 1969, upon the death of the AANM's long-time president, Mary Breckenridge, the AANM and the ACNM merged (Varney & Thompson, 2016). Growth of Midwifery Practice Public interest in natural childbirth that stemmed from the women's movement was particularly beneficial to the practice of nursemidwifery in the 1970s; the demand for nurse-midwifery services increased dramatically during that decade. In addition, sociopolitical developments, including the increased employment of CNMs in federally funded health care projects and the increased birth rate resulting from baby boomers reaching adulthood, converged with inadequate numbers of obstetricians to foster the rapid growth of CNM practice (Varney, Kriebs, & Gegor, 2004). In 1971 the ACNM, the American College of Obstetricians and Gynecologists, and the Nurses' Association of the American College of Obstetricians and Gynecologists issued a joint statement supporting the development and employment of nurse-midwives in obstetric teams directed by a physician. The joint statement, which was critical to the practice of nurse-midwifery, reflected some resolution of the interprofessional tension that had existed through much of the 20th century. However, it did not provide for autonomy for CNMs. Later in the decade, the ACNM revised its definitions of CNM practice and its philosophy, emphasizing the distinct midwifery and nursing origins of the role (ACNM, 1978a, 1978b). This conceptualization of nurse-midwifery as the combination of two disciplines, nursing and midwifery, was unique among the advanced practice nursing specialties. It served to align nurse-midwives with non-nurse midwives, thereby broadening their organizational and political base. Philosophically controversial, even within nurse-midwifery, the conceptualization created some distance from other APRN specialties that saw advanced practice roles as based solely in the discipline of nursing. This distinction would continue to isolate CNMs from some APRNs for the next several decades. By the 1980s, the public's acceptance of nurse-midwives had further grown, and demand for their services had increased among all socioeconomic groups. In 1982, there were almost 2600 CNMs, most located on the East Coast. “Nurse-midwifery had become not only acceptable but also desirable and demanded. Now the problem was that, after years during which nurse-midwives struggled for existence, there was nowhere near the supply to meet the demand” (Varney, 1987, p. 31). Another problem that intensified in the 1980s was the escalating cost of malpractice insurance. The critical issue for insurance companies at this time was the tension between covering a nursemidwife's planned normal healthy practice, with minimal risk, against the possibility of a complex delivery outcome. The annual cost of nurse-midwives' malpractice insurance rose from $38 annually in 1982 to about $3500 annually in 1986. This huge increase occurred when midwives earned, on average, $23,000 a year (Langton & Kammerer, 1985). The price of insurance was impacted by where nurse-midwives practiced—in a hospital, birthing center, or private home. Attending a delivery in a private home was the most risky because midwives lacked any immediate medical support. Due to the cost of insurance, many CNMs gave up delivering babies altogether; others sought employment in physicians' offices, public health departments, and hospitals in which they could be covered by their employers' policies. Some forfeited coverage completely. In 1987, an Arizona study found that about 10% of CNMs were practicing without insurance (Xu, Lori, Siefert, Jacobson, & Ransom, 2008). During the 1990s, increasing demand for CNM services resulted in a gradual expansion in the scope of nurse-midwifery practice. CNMs began to provide care to women with relatively high-risk pregnancies in collaboration with obstetricians in some of the nation's academic tertiary care centers (Rooks, 1997). During this decade, two practice models emerged: the CNM service model, in which CNMs were responsible for the care of a caseload of women determined to be eligible for midwifery care, and the CNM-physician team model. Nurse-midwives continued making progress in establishing laws and regulations needed to support their practice. However, the struggle for prescriptive authority continued until 2007, when Pennsylvania's nurse-midwives, the last in the country, finally received the right to prescribe (ACNM, 2007). Reimbursement Conflict with the medical profession arose as obstetricians perceived a growing threat to their practices. The denial of hospital privileges, attempts to deny third-party reimbursement, and state legislative battles over statutory recognition of CNMs ensued. In particular, problems concerning restraint of trade emerged. In 1980, the US Congress and the Federal Trade Commission conducted a hearing to determine the extent of the restraint of trade issues experienced by CNMs. In two cases, one in Tennessee and one in Georgia, the Federal Trade Commission obtained restraint orders against hospitals and insurance companies attempting to limit the practice of CNMs, in essence ensuring that CNMs could practice (Diers, 1991). Third-party reimbursement for CNMs was a second issue. In 1980, CNMs working under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS; now Tricare) for military dependents were the first to receive approval for reimbursement. Third-party payment for CNMs was also included under Medicaid. Statutory recognition by state legislatures was a third problem that would be addressed in the 1980s. By 1984, all 50 states had recognized nurse-midwifery in their state laws or regulations (Varney, 1987). Nurse-Midwifery: Later Education Much like nurse anesthetist programs had done before them, and indeed with help from the AANA, the midwifery organization acted to form an accrediting body; the first draft of their accreditation criteria appeared in 1962. Accreditation supported the midwives' aim to control their entry criteria and their professional education. Midwifery programs in the United States provided two different credentials: certificates and, later, master's degrees as midwifery programs emerged in university settings in the late 1950s. In 1966 accreditation criteria mandated that all nurse-midwifery programs had to be affiliated with a university (Varney & Thompson, 2016). In 2017, there were 40 master's programs in nurse-midwifery and just 7 post-baccalaureate DNP nurse-midwifery programs (AACN, 2017). In an interesting move, unlike other APRN professional organizations, the ACNM has stated that there is no evidence to support requiring a doctoral degree for entry into midwifery practice. They argue that current educational standards result in safe and positive outcomes for women and newborns. Therefore in 2012 the ACNM reaffirmed its 2007 position statement that the DNP is not required for entry into midwifery practice (ACNM, 2012). Current discussion of the nursemidwifery APRN role is presented in Chapter 17. Clinical Nurse Specialists The clinical nurse specialist evolved out of the increasing complexity of nursing care. The use of the term specialist in nursing can be traced to the turn of the 20th century, when hospitals offered postgraduate courses in various specialty areas, including anesthesia, tuberculosis, operating room, laboratory, and dietetics. In the first issue of the American Journal of Nursing, in an article titled “Specialties in Nursing,” Katherine Dewitt (1900) described specialty practice and the specialist's need for continuing education: Those who devote themselves to one branch of nursing often do so because of the keen interest they feel in it. The specialist can and should reach greater perfection in her sphere when she gives her entire time to it. Her studies should be continued in that direction, she should try constantly to keep up with the rapid advances in medical science. … The nurse who is a specialist can often supplement the doctor's work to a great extent. (p. 16) The roots of the CNS role lie in the area of psychiatric nursing, which had its origins in the Quaker reform movement initiated earlier in mid-19th century England. In the United States, these Quaker reformers challenged the brutal treatment of the insane and advocated “moral treatment,” emphasizing gentler methods of social control in a domestic setting (D'Antonio, 1991, p. 411). Psychiatric Nursing Specialists The first American training program for psychiatric nurses was founded in 1880 at McLean Hospital in Massachusetts (Critchley, 1985). According to Linda Richards, an 1873 graduate of the New England Hospital School of Nursing, the McLean Hospital maintained high standards and demonstrated “the value of trained nursing for the many persons afflicted with mental disease” (Richards, 1911, p. 109). Richards served as superintendent of nurses at the Taunton Insane Hospital for 4 years, beginning in 1899. She subsequently organized a nursing school for the preparation of psychiatric nurses at the Worcester Hospital for the Insane and finally went to the Michigan Insane Hospital in Kalamazoo, where she remained until 1909 (Richards, 1911). Because of this work, Richards is credited with founding the specialty of psychiatric nursing. During the first decades of the 20th century, Harry Stack Sullivan's classic writings and the work of Sigmund Freud changed psychiatric nursing dramatically. The emphasis on interpersonal interaction with patients and milieu treatment supported the movement of nurses into a more direct role in the psychiatric care of hospitalized patients. World War II influenced the specialty of psychiatric nursing because of an increased public awareness of psychiatric problems in returning soldiers (Critchley, 1985). During the 1940s, new treatments were introduced for the care of the mentally ill, including the widespread use of electroshock therapy, which required the assistance of nurses who had specialized knowledge and training. According to a 1942 American Journal of Nursing article, “Only the nurse skilled in her profession and with additional psychiatric background has a place in mental hospitals today” (Schindler, 1942, p. 861). By 1943, three postgraduate programs in psychiatric nursing had been established. As nurse educator Frances Reiter later reflected on her career, she recalled having first used the term nurse clinician in a speech in 1943 to describe a nurse with advanced “curative” knowledge and clinical competence committed to providing the highest quality of direct patient care (Reiter, 1966). In 1946, after Congress passed the National Mental Health Act designating psychiatric nursing as a core discipline in mental health, federal funding for graduate and undergraduate educational programs and research became available. Psychiatric nursing became established as a graduate-level specialty, one that would lead the way for clinical nurse specialization in the next decade. In 1954, Hildegarde E. Peplau, a professor of psychiatric nursing, established a master's program in psychiatric nursing at Rutgers University in New Jersey. Considered the first CNS education program, this program, and the growth of specialty knowledge in psychiatric nursing that ensued, provided support for psychiatric nurses to begin exploring new leadership roles in the care of patients with mental illness in inpatient and outpatient settings. Scholarship in psychiatric nursing also flourished, including Peplau's conceptual framework for psychiatric nursing. Her book, Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing (1952), provided theory-based practice for the specialty. Clearly, the link between academia and specialization was becoming stronger and the psychiatric specialty was leading the way. Coronary Care Nursing Specialists Cardiac rhythms, constantly visualized on the newly developed bedside monitors, required educated nurses and thus called for another early nursing clinical specialty. With the establishment of the Bethany Hospital Coronary Care Unit (CCU) in Kansas City, Kansas, in 1962 and a second unit at the Presbyterian Hospital in Philadelphia, coronary care nursing emerged as a new clinical specialty. As CCUs proliferated across the country with the support of federally funded regional medical programs, nurses and physicians acquired specialized clinical knowledge in the area of cardiology. Together, these nurses and physicians discussed clinical questions and negotiated responsibilities (Lynaugh & Fairman, 1992). In so doing, CCU nurses also expanded their scope of practice. Identifying cardiac arrhythmias, administering intravenous medications, and defibrillating patients who had lethal ventricular fibrillation, CCU nurses blurred the invisible boundary separating the disciplines of nursing and medicine. These nurses were diagnosing and treating patients in dramatic lifesaving situations, thereby challenging the very definition of nursing that had been published by the ANA only a few years earlier (Keeling, 2004, 2007) (Box 1.3 and Exemplar 1.3). Box 1.3 American Nurses Association Defines Nursing Practice (c. 1950s) The classic work of nurse scholar Virginia Henderson on scientifically based, patient-centered care laid the foundation for changes in nursing that would occur in the second half of the 20th century, including the development of APRNs. Influenced by Henderson and by Hildegarde Peplau, innovative nurses such as Frances Reiter at New York Medical College initiated a clinical nurse graduate curriculum designed to provide nurses with an intellectual clinical component based on a liberal arts education, in effect supporting a broader role for nurses (Fairman, 2001). However, although academic nursing was making strides toward establishing specialty education and expanding the nurse specialist's scope of practice, the ANA developed a model definition of nursing that would unduly restrict nursing practice for the next several decades. The definition, prepared in 1955 and adopted by many states, read as follows (ANA, 1955): The practice of professional nursing means the performance for compensation of any act in the observation, care and counsel of the ill … or in the maintenance of health or prevention of illness … or the administration of medications and treatments as prescribed by a licensed physician. … The foregoing shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measures. Although the ANA may simply have been seeking clarity in defining the discipline's boundaries, its exclusion of the acts of diagnosis and prescription stifled the development of advanced practice nursing. Discussing the impact of the ANA's restrictions on diagnosis and prescription, law professor Barbara Safriet (1992) argued: “Even at the time the ANA's model definition was issued … it was unduly restrictive when measured by then current nursing practice.” Nurses had been assessing patients for more than 50 years. According to historian Bonnie Bullough (1984), “The fascinating thing about the disclaimer [regarding diagnosis and prescription] is that it was made not by the American Medical Association, but the American Nurses Association. … In effect, organized nursing surrendered without any battle over boundaries.” The ANA's 1955 definition of nursing would restrict the expansion of nurses' scope of practice for the rest of the 20th century as the profession struggled with the dichotomy of care versus cure and of medical versus nursing diagnoses. In essence, the definition reversed years of hard-won gains in expanding the scope of nursing practice. Exemplar 1.3 Interprofessional Practice in the 1960s: Rose Pinneo and Lawrence Meltzer (Courtesy University of Virginia, Center for Nursing Historical Inquiry.) In 1962, Dr. Lawrence Meltzer, of the Presbyterian Hospital in Philadelphia, proposed that the role of the nurse would be central to the new system of coronary care. The nurse would be present in the coronary care unit (CCU) 24 hours a day. When the research project began on January 15, 1963, about 8 months after the Hartford CCU opened in Kansas City, Meltzer immediately faced the challenge of staffing it. Rose Pinneo, RN, MSN, a graduate of both Johns Hopkins School of Nursing and the University of Pennsylvania, agreed to be the nursing director. In July 1963, 6 months after agreeing to accept the job, Pinneo, a small-framed, unassuming professional, took on the nursing leadership role in the new unit, implementing the new role for nurses (Pinneo, 1967). In the CCUs in the 1960s, clinical expertise on the part of the nurse would be invaluable. As Pinneo described it, “The nurses' role is more complex than that of the usual hospital nurse”, and she went on to explain it further: Utilizing the unique combination of clinical assessment and cardiac monitoring, the nurse makes independent decisions. She determines those situations requiring her immediate intervention to save life prior to the physician's arrival or those situations that warrant calling the physician and waiting for his evaluation. It is in these precious moments that the patient's life may literally be in the hands of the nurse. (Pinneo, 1972, p. 4) Collaboration with physicians at the grassroots level would be key to the CCU nurses' success. Pinneo and other nurses who worked in the first CCUs worked closely with cardiologists (Keeling, 2004), and interprofessional on-the-job training was the norm. These changes in setting, technology, and expectations of the nurse exemplify stage I in the transition of specialties into advanced practice nursing (see Chapter 5). The creation of the CCU initiated a new era for nurses. The changes that occurred in the clinical setting of the CCU helped establish collegial relationships between nurses and physicians that would be important for advanced practice registered nurses in the decades to follow. In intensive care units and CCUs, collaborative practice was essential. “Most importantly, nurses and physicians learned to trust each other” (Lynaugh & Fairman, 1992, p. 24). Growth of Clinical Nurse Specialist Practice The 1960s are most often noted as the decade in which clinical nurse specialization took its modern form. After the enactment of the Nurse Training Act of 1964, numerous CNS master's programs were created. Peplau (1965) contended that three social forces precede the development of areas of specialization: (1) an increase in specialtyrelated information, (2) new technologic advances, and (3) a response to public need and interest. In addition to shaping most nursing specialties, these forces had a particularly strong effect on the development of the psychiatric CNS role in the 1960s. The Community Mental Health Centers Act of 1963, as well as the growing interest in child and adolescent mental health care, directly enhanced the expansion of that role in outpatient mental health care. A rapid proliferation of CNS programs and jobs, as well as an emerging role ambiguity and confusion that accompanied them, defined the 1970s for CNSs. During this decade, psychiatric CNSs continued to provide leadership in the educational and clinical arenas while federal funding from the Professional Nurse Traineeship Program provided fiscal support for new programs. In addition to psychiatric and coronary care specializations, the specialties of critical care and oncology nursing also grew during the 1970s. The American Association of Critical-Care Nurses, founded in 1969 as the American Association of Cardiovascular Nurses, addressed the continuing educational needs of new specialists in the areas of coronary care and intensive care nursing. Only 4 years later, after the ANA and American Cancer Society sponsored the first National Cancer Nursing Research Conference, a group of oncology nurses met to discuss the need for a national organization to support their specialty. Officially incorporated in 1975, the Oncology Nursing Society provided a forum for issues related to cancer nursing and supported the growth of advanced practice nursing in this specialty (Lusk, 2005; Oncology Nursing Society, 2011). The ANA officially recognized the CNS role in the mid-1970s, defining the CNS as an expert practitioner and change agent. The ANA's definition specified a master's degree as a requirement for the CNS (ANA Congress of Nursing Practice, 1974). As with the other advanced nursing specialties of nurse anesthesia and midwifery, the development of the CNS role included early evaluation research that served to validate and promote this new role. Georgopoulos and colleagues (Georgopoulos & Christman, 1970; Georgopoulos & Jackson, 1970; Georgopoulos & Sana, 1971) conducted studies evaluating the effect of CNS practice on the nursing process and outcomes in inpatient adult health care settings. These and other evaluative studies (Ayers, 1971; Girouard, 1978; Little & Carnevali, 1967) demonstrated the positive effect of the CNS on improving nursing care and patient outcomes. Moreover, with the increasing demand from society to cure illness using the latest scientific and technologic advances, hospital administrators willingly supported specialization in nursing and hired CNSs, particularly in the revenue-producing intensive care units. The CNS role remained the dominant APRN role in the 1980s, with CNSs representing 42% of all APRNs (US Department of Health and Human Services, 1996). The ANA's Social Policy Statement (ANA, 1980) clearly delineated the criteria required to assume the title of CNS and was of particular significance to the maturation of the CNS role during this decade. According to that statement, The specialist in nursing practice is a nurse who, through study and supervised clinical practice at the graduate level (master's or doctorate), has become expert in a defined area of knowledge and practice in a selected clinical area of nursing. … Upon completion of a graduate program degree in a university graduate program with an emphasis on clinical specialization, the specialist in nursing practice should meet the criteria for specialty certification through nursing's professional society. (ANA, 1980, p. 23) By 1984, the National League for Nursing had accredited 129 programs for the preparation of CNSs. These new, clinically focused graduate programs were instrumental in developing and defining the CNS role. Concurrently, some nurse researchers once again studied the outcomes related to CNS practice. In 1987, for example, McBride and colleagues demonstrated that nursing practice, particularly in relation to documentation, improved as a result of the introduction of a CNS in an inpatient psychiatric setting. However, at about that time, health care cost containment raised concerns about the future of the CNS role (Hamric, 1989). Declining Demand for Clinical Nurse Specialists By the late 1980s, many CNSs had shifted the focus of their practice away from the clinical area and instead focused on the educational and organizational aspects of the CNS role, such as orientation programs, in-service education, and administrative functions. This shift was supported by the view that CNSs were too valuable to spend their time on direct patient care (Wolff, 1984). Meanwhile, others who continued to assert that the essence of the CNS role was clinical expertise were publishing articles and books on the topic (Hamric & Spross, 1983, 1989; Sparacino, 1990). The increasing emphasis on cost containment in the 1980s produced legislative and economic changes that affected advanced practice nursing and the health care delivery system as a whole (Box 1.4). In particular, the establishment of a prospective payment system in 1983 was a landmark event. This payment system, which used diagnosisrelated groups to classify billing for hospitalized Medicare recipients, represented an effort to control rising costs by shifting reimbursement from payment for services provided to payment by case (capitation). As a result, hospital administrators put increasing pressure on nurses and physicians to save money by decreasing the length of time patients remained hospitalized. The emphasis on cost containment also heralded budget cuts for hospitals. The CNS role came under intense review at this time. CNSs were not obviously cost-effective or overtly essential to patient care. The outcomes of the CNS role had not been empirically tracked and the role was poorly defined. The result was the elimination of some CNS positions by the end of the decade. Box 1.4 Access to Cost-Effective, Quality Health Care for All Americans The need to provide cost-effective, quality health care to US citizens prompted the Senate Committee on Appropriations to request a report from the Office of Technology Assessment on the contributions of nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants in meeting the nation's health care needs. The 1986 report, entitled Nurse Practitioners, Physician Assistants and Certified Nurse-Midwives: A Policy Analysis, was based on an analysis of numerous studies that assessed quality of care, patient satisfaction, and physician acceptance. It concluded, “within their areas of competence NPs … and CNMs provide care whose quality is equivalent to that of care provided by physicians” (Office of Technology Assessment, 1986). However, while the Office of Technology Assessment was conducting this study, the American Medical Association House of Delegates, threatened by the possibility of competition from advanced practice registered nurses, passed a resolution to “oppose any attempt at empowering nonphysicians to become unsupervised primary care providers and be directly reimbursed” (Safriet, 1992). The decade of the 1990s opened with cutbacks in employment opportunities for CNSs because of the financial problems in hospitals and closed with the federal government's recognition of Medicare reimbursement for CNS services. The cost of health care was a constant concern and, when President Clinton was elected in 1992, the country was in serious need of health care reform. Determined to take a proactive stance in the movement, the ANA wrote its Agenda for Health Care Reform (ANA, 1992). The plan focused on restructuring the US health care system to reduce costs and improve access to care. Although the Clinton administration's efforts for reform failed, radical changes were made by the private sector, in which the once-dominant fee-for-service insurance plans were overtaken by managed care organizations (Safriet, 1998). The changing marketplace created new challenges for APRNs as they struggled not only with restrictive, outdated state laws on prescriptive authority, but also with “nongovernmental, market-based impediments” to their practices (Safriet, 1998, p. 25). In this environment, APRNs continued to expand their roles, educational programs, and practice settings. Nationwide, in the opening years of the 1990s, CNS programs were still the most numerous of all master's nursing programs, with more than 11,000 students enrolled (National League for Nursing, 1994). The largest area of specialization was adult health–medical-surgical nursing. However, with the increasing emphasis on primary care in the mid-1990s, the rapid growth of NP programs, the financial challenges faced by hospital administrators, and the introduction of the ACNP role in tertiary care centers, the number of CNS positions in hospitals declined sharply. The 1996 National Sample Survey of Registered Nurses revealed that a significant number (7802) of CNSs were also prepared as NPs, educated to diagnose and treat health conditions (US Department of Health and Human Services, 1996). According to the National Sample Survey, these dual-role–prepared APRNs were more likely to be employed as NPs than as CNSs. By that time, of the 61,601 CNSs in the United States, only 23% were practicing in CNS-specific positions (US Department of Health and Human Services, 1996). This low percentage may have reflected the fact that CNSs accepted different positions—for example, as administrators or staff educators. It may also have reflected the decline in the number of CNS positions available because of budget cutbacks. Clinical Nurse Specialist Education and Reimbursement Education for CNS practice was complicated due to the number of specialties involved. In many specialties, existing certification examinations were targeted to nurses who were experts by experience, not graduates of master's programs that specifically trained them for specialty practice. Thus advanced-level certification for the CNS was slow to emerge. For example, it was not until 1995 that the Oncology Nursing Society administered the first certification examination for advanced practice in oncology nursing. A further complication was that not all states recognized these examinations for APRN regulatory purposes. In 2013, there were 148 schools offering a master's degree as a CNS and 18 offering a post-baccalaureate DNP CNS. Enrollment, however, was low, totaling just over 2200 students (AACN, 2015). As of Spring 2016, CNSs could practice to the full extent of their education and training in 28 states and could practice in collaboration with a physician in an additional 13 states. The ability of CNSs to prescribe medications and durable medical equipment depended on state regulations, which gradually allowed prescriptive authority to more CNSs (NACNS, 2015a). CNSs are now authorized to prescribe without physician supervision in 20 states (NACNS, 2015b).The National Association of Clinical Nurse Specialists (NACNS) was formed in 1995, promoting organization of the role at the national level. Soon thereafter, the Balanced Budget Act of 1997 specifically identified CNSs as eligible for Medicare reimbursement (Safriet, 1998). The law, providing Medicare Part B direct payment to NPs and CNSs regardless of their geographic area of practice, allowed both types of APRNs to be paid 85% of the fee paid to physicians for the same services. Moreover, the law's inclusion and definition of CNSs corrected the previous omission of this group from reimbursement (Safriet, 1998). The possibility of reimbursement for services was an important step in the continuing development of the CNS role because hospital administrators would continue to focus on the cost of having APRNs provide patient care. The creation of the NACNS, followed by third-party reimbursement for their services, represented two major steps for the CNS. The NACNS developed core competencies and criteria for the evaluation of CNS graduate programs and certificates. Practice competency varies by specialty and is the responsibility of over 20 professional organizations, although all must include the NACNS core competencies (NACNS, 2015c). In 2015, the NACNS endorsed the DNP as entry to practice for CNSs by 2030; previously they had been neutral on this question (NACNS, 2015c). Recent aspects of the CNS role are discussed in Chapter 14. Nurse Practitioners NPs provide care through diagnosis and treatment as well as addressing disease prevention and health management. The idea of using nurses to provide what we now refer to as primary care services dates to the late 19th century. During this period of rapid industrialization and social reform, public health nurses played a major role in providing care for poverty-stricken immigrants in cities throughout the country. The Henry Street Settlement and Primary Care In 1893, Lillian Wald, a young graduate nurse from the New York Training School for Nurses, established the Henry Street Settlement (HSS) House on the Lower East Side of Manhattan. Its purpose was to address the needs of the poor, many of whom lived in overcrowded, rat-infested tenements. For several decades, the HSS visiting nurses, like other district nurses, visited thousands of patients, with little interference in their work (Wald, 1922). The needs of this disadvantaged community were limitless. According to one account (Duffus, 1938): There were nursing infants, many of them with the summer bowel complaint that sent infant mortality soaring during the hot months; there were children with measles, not quarantined; there were children with ophthalmia, a contagious eye disease; there were children scarred with vermin bites; there were adults with typhoid; there was a case of puerperal septicemia, lying on a vermin-infested bed without sheets or pillow cases; a family consisting of a pregnant mother, a crippled child and two others living on dry bread … a young girl dying of tuberculosis amid the very conditions that had produced the disease. (p. 43) In addition to making home visits, the HSS nurses saw patients in the nurses' dispensary in the settlement house. There they treated “simple complaints and emergencies not requiring referral elsewhere” (Buhler-Wilkerson, 2001). For a time, their work usually went unnoticed, but interprofessional conflict was inevitable. According to nurse historian Karen Buhler-Wilkerson (2001): As the number of ambulatory visits grew, the settlement risked attracting the unwelcome attention of the increasingly disagreeable “uptown docs.” The New York Medical Society's recent success in attaching a clause to the Nursing Registration Bill prohibiting nurses from practicing medicine gave the society a new opportunity to disrupt the settlement's neighborly activities. … By 1904 … Lavinia Dock [a colleague of Lillian Wald] wrote to Wald about doctors' concerns that nurses were “carrying ointments and even giving pills” outside the strict control of physicians. (p. 110) To resolve this problem, the HSS nurses obtained standing orders for emergency medications and treatments from a group of Lower East Side physicians (Buhler-Wilkerson, 2001; Keeling, 2007). Nonetheless, conflicts with medicine surfaced again when the HHS nurses expanded their visits to areas of the city outside the Lower East Side. The situation came to a head with the collapse of the stock market in 1929, when uptown physicians apparently saw the nurses as an economic threat. That year, the Westchester Village Medical Group accused the nurses of practicing medicine. Angered by the accusation, Elizabeth MacKenzie, Associate Director of Nurses at the HSS, defended the HSS nurses in her reply (MacKenzie, 1929): My dear Dr. Black: Your letter … addressed to Miss Elizabeth Neary, Supervisor of our Westchester Office, has been referred to me for reply. May I call the attention of your group to the fact that in administering the work in that office, Miss Neary does so as a representative of the HSS Visiting Nurse Service and in accord with definite policies in effect throughout the entire city-wide service. It has been the unvarying policy of the organization over the 35 years of its service to work in close cooperation with the medical profession doing nursing and preventive health work entirely and avoiding any semblance of the “practice of medicine” in competition with the doctors. … We will call a meeting … to which the members of your group will be invited for a frank discussion of our common problems. Although the records about this meeting are no longer available, one can assume that the meeting happened and the nurses continued to practice because HSS remained active until the 1950s. Nonetheless, as is apparent in these two scenarios, from early in the 20th century there was evidence of interprofessional conflicts as nurses began to expand their scope of practice. There is also evidence of emerging collaboration between the professions as physicians and nurses negotiated solutions to the boundary problems. What is clear, even in those early years, is that nurses were considered “good enough” to care for the poor, whereas physicians would care for those who could pay. The Frontier Nursing Service and Other Examples of Early Primary Care In addition to providing midwifery services, FNS nurses in Leslie County, Kentucky, informally modeled what would later become the primary care NP role. During the 1930s, the FNS continued the work that Breckinridge had started in 1925, providing most of the primary health care needed by people living in rural Appalachia. Working out of eight centers that covered 78 square miles in remote mountainous regions, the FNS nurses had considerable autonomy. They made diagnoses and treated patients, dispensing herbs and medicines (including morphine) with the permission of their medical advisory committee. Working from standing orders written by that committee, the nurses also dispensed medicines such as aspirin, ipecac, cascara, and castor oil at their own discretion (FNS, 1948). That unprecedented autonomy in practice was not always recognized, however, even by the FNS nurses themselves. During an interview in 1978, FNS nurse Betty Lester reflected on her work as assistant field supervisor in Leslie County in the 1930s (Keeling, 2007): See, we nurses don't prescribe and we don't diagnose. We can make a tentative diagnosis and we can give that to the doctor, and if there's anything wrong then he'll tell us how to treat it. So they [the doctors] gave us this routine of things that we could use and the things we could do—and the things we couldn't do. (p. 49) Lester denied the extent of the practice autonomy she had had. Like other registered nurses of the era, she had been socialized to defer to physicians' judgment and orders. So, recalling her practice later in her life, Lester acknowledged only that she and her colleagues had made “tentative” diagnoses. In reality, she had practiced on her own because there were few telephones in the isolated community and even fewer physicians available for personal consultation. For all practical purposes, the diagnoses she had made were the only diagnoses and the treatment she had given was the only treatment (Keeling, 2007). During the 1930s, in addition to the FNS nurses, other nurses working among the poor in rural areas also practiced with exceptional autonomy. In particular, the Farm Security Administration (FSA) nurses “were given unusual latitude in their clinical roles” (Grey, 1999, p. 94) in migrant health clinics across the United States. According to historian Michael Grey (1999), who chronicled the history of rural health programs established by President Franklin D. Roosevelt during the Great Depression, which began in 1929 and lasted through approximately 1940: With the verbal approval of the camp doctor, they [FSA nurses] could write prescriptions and dispense drugs from the clinic formulary. … They staffed well baby clinics, coordinated immunization programs … decided whether a sick migrant required referral to a physician … and provided emergency care. (p. 94) Like the FNS nurses, FSA nurses practiced according to standing orders issued by the FSA medical offices and approved by local physicians. As Dr. H. Daniels recalled in a 1984 interview, “Nurses functioned pretty autonomously. They were able to do a lot of what NPs do after a lot of training, but these nurses did it through experience” (Grey, 1999, p. 96). Essential to this practice autonomy for the FNS and FSA nurses was the tacit requirement that the patients be poor and marginalized and have little access to physician-provided medical care. The same requirements held true for the field nurses working with the Bureau of Indian Affairs (BIA) in the first half of the 20th century, who often found themselves traveling the reservations alone, making diagnoses and treating patients. In addition to making home visits, BIA nurses conducted well-baby “nursing conferences,” the initial intent of which was health education and disease prevention. In actuality, these conferences became what are referred to today as nurse-run clinics; Navajo mothers would bring in sick infants and children to be seen by the nurse (Keeling, 2007). Reporting on her work at Teec Nos Pas in the Northern Navajo region in May 1931, nurse Dorothy Williams described the reality of providing muchneeded care of ear infections, sore throats, skin infections, and other commonly occurring problems. Williams referred to the conferences as “clinics”: Five clinics held this week, three general and two baby clinics. Mothers bathed their babies and were given material to cut out and make gowns for baby. Preschool children were weighed, inspected and mothers advised about diets for underweights [sic]. … Fifty treatments given (Williams, 2007). Although the NP role had been modeled informally in the FNS in the 1930s, it was during the 1960s that the role was first described formally and implemented in outpatient pediatric clinics, originating in part as a response to a shortage of primary care physicians. As the trend toward medical specialization drew increasing numbers of physicians away from primary care, many areas of the country were designated underserved with respect to the numbers of primary care physicians. “Report after report issued by the AMA [American Medical Association] and the Association of American Medical Colleges decried the shortage of physicians in poor rural and urban areas” (Fairman, 2002, p. 163). At the same time, consumers across the nation were demanding accessible, affordable, and sensitive health care while health care delivery costs were increasing at an annual rate of 10% to 14% (Jonas, 1981). Growth of Nurse Practitioner Practice The event marking the inception of the modern NP role was the establishment of the first pediatric NP (PNP) program by Loretta Ford, RN, and Henry Silver, MD, at the University of Colorado in 1965. This demonstration project, funded by the Commonwealth Foundation, was designed to prepare professional nurses to provide comprehensive well-child care and manage common childhood health problems. The 4-month program, during which certified registered nurses were educated as PNPs without requiring master's preparation, emphasized health promotion and inclusion of the family. A study evaluating the project demonstrated that PNPs were highly competent in assessing and managing 75% of well and ill children in community health settings. In addition, PNPs increased the number of patients served in private pediatric practice by 33% (Ford & Silver, 1967). Like early nurse-midwife and nurse anesthetist studies, these positive findings demonstrated support for this new nursing role. The PNP role was not without significant intraprofessional controversy, particularly with regard to educational preparation. Early on, certificate programs based on the Colorado project rapidly sprang into existence. According to Ford (1991), some of these programs shifted the emphasis of PNP preparation from a nursing to a medical model. This was in contrast to the original University of Colorado demonstration project that stressed collaboration between nursing and medicine (Exemplar 1.4). As a result, one of the major areas of controversy in academia was over the fact that NPs made medical diagnoses and wrote prescriptions for medications, essentially stepping over the invisible medical boundary into the realm of curing. Because of this, some nurse educators and other nurse leaders questioned whether the NP role could be conceptualized as being within the discipline of nursing, a profession that had historically been ordered to care (Reverby, 1987; Rogers, 1972). Exemplar 1.4 Loretta Ford: Cofounder, with Henry Silver, of the Nurse Practitioner Role There was a spirit of excitement, of anger, and of tremendous possibility in the United States of the 1960s. Americans marched for civil rights, President's Johnson's “War on Poverty” had begun, and people demanded access to health care. Within nursing, the American Nurses Association called for requiring the baccalaureate degree for entry into practice, while Dr. Loretta Ford, a nurse, and Dr. Henry Silver, a pediatrician, introduced the concept of the nurse practitioner. Silver saw an unmet need for pediatric health care providers and he thought that appropriately educated nurses could offer it, but nurse educators were resistant. Then he met Loretta Ford. She was excited; she understood the potential of expanding care through allowing nurses to practice to the fullest extent of advanced nursing education (Pearson, 1985). The term nurse practitioner was coined, Ford later explained, because “So many nurses in a specialty were either teachers or administrators, not practitioners of nursing. We wanted to emphasize the clinical practice role” (Jacox, 2002, p. 162). “Abuse and misuse of nurses became obvious,” she noted at another time. “Nurses were doing so many things. Mostly they were nursing the system, nursing the doctors, nursing the desk, nursing everything else but the patients” (“An interview with Dr. Loretta Ford,” 1975, p. 10). Ford consistently stated that nurse practitioners must align their professional stance with nursing and not focus on a medical orientation (Pearson, 1985). She argued that nurse practitioners should diagnose “within the context of the patient's health status, social qualities, physical characteristics, and economic realities: within the patient's personality and strength. … They must understand the importance of caring and compassion” (Pearson, 1999, pp. 25–6). To underscore this, Ford further argued that today's practitioners must know their history. “Maybe they know about Florence Nightingale, but they don't know all of the things that Florence Nightingale had as basic tenets of the nursing that she started” (O'Grady & Lusk, 2016). Loretta Ford's career as a nursing exemplar mirrors advice she has given to today's nurses: “The future belongs to those who are committed, courageous, competent, compassionate—and to those with enough chutzpah to create their own destiny” (Jacox, 2002, p. 164). While nursing professors debated the educational preparation of NPs (Keeling, 2007; Rogers, 1972), the NP role attracted considerable attention from professional groups and policymakers. Health policy groups such as the National Advisory Commission on Health Manpower issued statements in support of the NP concept (Moxley, 1968). At the grassroots level, physicians accepted the new role and hired NPs. The NP role had already appeared in the practice setting. In the 1970s, NPs continued to enhance their visibility in the health care system, negotiating with physicians to expand their scope of practice and demonstrating their cost-effectiveness in providing quality care. Nevertheless, it was also a period characterized by intraprofessional conflict because some leaders in the nursing community continued to reject the role. In contrast, state legislatures increasingly recognized these expanded roles of registered nurses and a group of pro-NP nursing faculty, already teaching in NP programs, held their first national meeting in Chapel Hill, North Carolina, in 1974. This meeting would lay the foundation for the formation of the National Organization of Nurse Practitioner Faculties (NONPF). In the early 1970s, US Department of Health, Education, and Welfare Secretary Elliott Richardson established the Committee to Study Extended Roles for Nurses. This group of health care leaders was charged with evaluating the feasibility of expanding nursing practice (Kalisch & Kalisch, 1986). They concluded that extending the scope of the nurse's role was essential to providing equal access to health care for all Americans. According to an editorial in the American Journal of Nursing, “The kind of health care Lillian Wald began preaching and practicing in 1893 is the kind the people of this country are still crying for” (Schutt, 1971, p. 53). The committee urged the establishment of innovative curricular designs in health science centers and increased financial support for nursing education. It also advocated standardizing nursing licensure and national certification and developing a model nurse practice law suitable for national application. In addition, the committee called for further research related to cost-benefit analyses and attitudinal surveys to assess the impact of the NP role. This report resulted in increased federal support for training programs for the preparation of several types of NPs, including family NPs, adult NPs, and emergency department NPs (Kalisch & Kalisch, 1986). Controversy and Support for the Nurse Practitioner's Role Conflict and discord about the NP role continued to characterize relationships between NPs and other nurses. Some academics who believed that NPs were not practicing nursing continued to pose resistance to the role (Ford, 1982). Nurse theorist Martha Rogers, one of the most outspoken opponents of the NP concept, argued that the development of the NP role was a ploy to lure nurses away from nursing to medicine, thereby undermining nursing's unique role in health care (Rogers, 1972). Subsequently, nurse leaders and educators took sides for and against the establishment of educational programs for NPs in mainstream master's programs. Over time, the standardization of NP educational programs at the master's level, initiated by the group of faculty who formed the NONPF, would serve to reduce intraprofessional tension. Despite the resistance to NPs in nursing, physicians increasingly accepted NPs in individual health care practices. Working together in local practices, NPs and MDs established collegial relationships, negotiating with each other to construct work boundaries and reach agreement about their collaborative practice. “In the NP-MD dyad, negotiations centered on the NP's right to practice an essential part of traditional medicine: the process or skill set of clinical thinking … to perform a physical examination, elicit patient symptoms, … create a diagnosis, formulate treatment options, prescribe treatment and make decisions about prognosis” (Fairman, 2002, pp. 163–164). The proximity of a supervising physician was thought to be key to effective practice, and on-site supervision was the norm. Grassroots acceptance of the role was dependent on tight physician supervision and control of the protocols under which NPs practiced. That supervision was not without benefit to the newly certified, inexperienced NPs. According to Corene Johnson, “Initially, we had to always have a physician on site. … I didn't resent that. Actually, I needed the backup” (Fairman, 2002, p. 164). During the 1980s, the concept of advanced nursing practice began to be defined and used in the literature. In 1983, Harriet Kitzman, an associate professor at the University of Rochester, explored the interrelationships between CNSs and NPs (Kitzman, 1983). She used the term advanced practice throughout her discussion, applying the term not only to advanced education, but also to CNS and NP practice. She noted, “Recognition for advanced practice competence is already established for both NPs and CNSs through the profession's certification programs. … advanced nursing practice cannot be setting-bound, because nursing needs are not exclusively setting- restricted” (Kitzman, 1983, pp. 284, 288). At about this time, the Council of Primary Health Care Nurse Practitioners and the Council of Clinical Nurse Specialists began to explore the commonalities of the two roles. In 1988, the councils conducted a survey of all NP and CNS graduate programs and identified considerable overlap in curricula. Subsequently, between 1988 and 1990, the two councils discussed a proposal to merge, and, in 1991, the Council of Nurses in Advanced Practice was formed. Unfortunately, the merger was short-lived because of the restructuring of the ANA during the early 1990s. Nevertheless, it was an important step in the organizational coalescence of advanced practice nursing (ANA, 1991). In 1984, an associate professor at the University of Wisconsin–Madison, Joy Calkin, proposed a model for advanced nursing practice, specifically identifying CNSs and NPs with master's degrees as APRNs (Calkin, 1984). By the end of the decade, the nursing literature was increasingly using the term. Published in 1996, the first edition of this text included CRNA and CNM roles as advanced practice nursing, reflecting an integrative vision of advanced practice that was increasingly being seen in the literature. Although physicians and NPs collaborated at the local level, organized medicine began to increase its resistance to the NP role. One of the most contentious areas of interprofessional conflict involved prescriptive authority for nursing (Box 1.5). As one author so aptly noted, “Nursing's efforts to obtain the legal authority to prescribe may be seen as the second chapter in the struggle over the use of the word ‘diagnosing’ in Nurse Practice Acts” (Hadley, 1989, p. 291). Basically, prescriptive authority, regarded as a delegated medical act, was dependent on NPs' legal right to provide treatment. In 1971, Idaho became the first state to recognize diagnosis and treatment as part of the scope of practice of specialty nurses (Idaho Code § 54-1413, 1971). However, “As path-breaking as the statute was, it was still rather restrictive in that any acts of diagnosis and treatment had to be authorized by rules and regulations promulgated by the Idaho State Boards of Medicine and Nursing” (Safriet, 1992, p. 445). Moreover, the Drug Enforcement Act required that practitioners wishing to prescribe controlled substances obtain US Drug Enforcement Administration (DEA) registration numbers, and only those practitioners with broad prescriptive authority (e.g., physicians and dentists) could obtain these numbers. Box 1.5 The Fight for Nurse Practitioner Prescriptive Privileges The fight for prescriptive authority for nurse practitioners (NPs) spanned the latter decades of the 20th century. By 1983, only Oregon and Washington granted NPs statutory, independent prescriptive authority. Other states granting prescriptive authority to NPs did so with the provision that a licensed physician directly supervises the NP. How prescriptions were handled depended on the availability of the physician, negotiated boundaries of the individual physician-NP team, and the state in which practice occurred. In some cases, that meant that physicians pre-signed a pad of prescriptions for the NP to use at her or his discretion; in remote area clinics, such as those in the Frontier Nursing Service, a physician would countersign NP prescriptions once a week and, in other cases, the physician would write and sign a prescription at the request of the NP. With the exception of the latter, these practices were of questionable legality (Keeling, 2007). Growth in Nurse Practitioner Numbers and Expanded Scope of Practice Significant growth in the numbers of NPs in practice and the fight for prescriptive authority for NPs characterized the 1980s. NP practice increased immeasurably during this time as new types of NPs developed, the most significant of which were the emergency NP, neonatal NP, and family NP. By 1984, approximately 20,000 graduates of NP programs were employed, for the most part, in settings “that the founders envisioned” (Kalisch & Kalisch, 1986, p. 715): outpatient clinics, health maintenance organizations, health departments, community health centers, rural clinics, schools, occupational health clinics, and private offices. By the late 1980s, however, based on their success in neonatal intensive care units, NPs with specialty preparation were increasingly being used in tertiary care centers (Silver & McAtee, 1988). During this period, the multiple roles for NPs created competing interests that would affect their ability to speak with one voice on legislative issues. In an attempt to rectify this situation, the ANA established the Primary Health Care Nurse Practitioner Council. At about the same time, the American Academy of Nurse Practitioners was established in 1985 as the first organization for NPs from all specializations. In 1995 a competing NP organization was formed to serve as a “SWAT team” on policy during President Clinton's health care reform initiative. Named the American College of Nurse Practitioners, the new organization was seen as an umbrella organization to bring all the NP organizations together. Throughout the 1980s, NPs worked tirelessly to convince state legislatures to pass laws and establish reimbursement policies that would support their practice. Interprofessional conflicts with organized medicine, and to a lesser extent with pharmacists, centered on control issues and the degree of independence the NP was allowed. These conflicts intensified as NPs moved beyond the physician extender model to a more autonomous one. In a seminal case, Sermchief v. Gonzales (1983), the Missouri medical board charged two women's health care NPs with practicing medicine without a license (Doyle & Meurer, 1983). The initial ruling was against the NPs but, on appeal, the Missouri Supreme Court overturned the decision, concluding that the scope of practice of APRNs could evolve without statutory constraints (Wolff, 1984). In essence, this case provided a model for new state nurse practice acts to address issues related to APRN practice with very generalized wording, a change that allowed for expansion in the roles and functions of APRNs. In the early 1990s, federal legislation regulating narcotics in the Controlled Substances Act would be of major significance to NP progress in implementing prescriptive authority. As NPs began to gain prescriptive authority for controlled substances in different states, they required a parallel authority granted by the DEA. In 1991, the DEA first responded to this situation by proposing registration for “affiliated practitioners” (Definition and Exemption of Affiliated Practitioners for the Drug Enforcement Administration, 1991). This proposal called for those NPs who had prescriptive authority pursuant to a practice protocol or collaborative practice agreement to be assigned a registration number for controlled substances tied to the number of the physician with whom they worked. This proposal received much criticism specifically related to the restriction of access to health care and the legal liability of the prescribers, and the proposal was revoked in 1992. Later that year, the DEA amended its regulations by adding a category of “mid-level providers” (MLPs), who would be issued individual provider DEA numbers as long as they were granted prescriptive authority by the state in which they practiced. The MLP's number would begin with an M for mid-level provider, rather than an A or B. The MLP provision took effect in 1993, significantly expanding NPs' ability to prescribe. Neonatal and Acute Care Nurse Practitioners One of the newer types of NPs to emerge was the neonatal NP. Originating in the late 1970s in response to a shortage of neonatologists coinciding with restrictions in the total time pediatric residents could devote to neonatal intensive care, the neonatal NP was the forerunner of the acute care NP of the 1990s. These highly skilled, experienced neonatal nurses assumed a wide range of new responsibilities formerly undertaken by pediatric residents, including interhospital transport of critically ill infants and newborn resuscitation (Clancy & Maguire, 1995). Like the earlier neonatal NP role, the adult acute care NP (ACNP) role grew in response to residency shortages in intensive care units, although this time the shortage was because of decreases in the number of residents available to work in the medical subspecialties. In addition, increasingly complicated tertiary care systems lacked coordination of care. Advanced practice nursing responded quickly to this need, building on the earlier work of Silver and McAtee (1988) to create a role that promoted quality patient care and nursing's leadership in health care delivery (Daly, 1997). University of Pennsylvania professors Anne Keane and Therese Richmond were among those who documented the emergence of the tertiary NP (TNP): The TNP is an advanced practice nurse educated at the master's level with both a theoretical and experiential focus on complex patients with specialized health needs. … There is precedent for the NP in tertiary care. For example, neonatal nurse practitioners are central to the provision of care in many intensive care nurseries. … It is our belief that the TNP can provide clinically expert specialized care in a holistic manner in a system that is often typified by fragmentation, lack of communication among medical specialists, and a loss of recognition of the patient and patient's needs as central to the care delivered. (Keane & Richmond, 1993, p. 282) From 1992 to 1995, acute care nurse practitioner (ACNP) tracks in master's programs proliferated across the country. Soon, questions abounded concerning the content of the curriculum. To resolve these, educators met annually at ACNP consensus conferences, beginning in 1993. The ANA's Credentialing Center administered the first ACNP certification examination in December 1995. By 1997, there were 43 programs nationwide that prepared ACNPs at the master's or postmaster's level (Kleinpell, 1997). In 2002, the ACNPs formally merged with the American Academy of Nurse Practitioners, with the goal of uniting primary care NPs and ACNPs under an umbrella organization. By this time, ACNPs were employed in multiple specialties, including cardiology, cardiovascular surgery, neurosurgery, emergency and trauma, internal medicine, and radiology services (Daly, 2002). During this decade, the growth in the number of NP programs, increase in prescriptive authority for NPs, and autonomy that NPs found in their practice settings converged to make the NP role enticing, and increasing numbers of nurses who wanted to be APRNs chose the NP role. The problem was that there were a number of organizations speaking for the various types of NPs. The American Academy of Nurse Practitioners continued to be active after the American College of Nurse Practitioners was founded in 1995. In addition, PNPs formed the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP), and nurses interested in women's health issues formed the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). These groups soon offered their own certification examinations, in competition with those offered by the ANA's Credentialing Center. One thing that they did agree on, however, was education for practice. In August 1993, representatives of 63 of 66 tricouncil organizations attending a national nursing summit agreed to require master's education for the NP role (Cronenwett, 1995). In 2013 the American Academy of Nurse Practitioners and the American College of Nurse Practitioners merged to form the American Association of Nurse Practitioners (AANP, 2013a). Nurse Practitioner Education During the 1990s, the number of NPs increased dramatically in response to increasing demand, the national emphasis on primary care, and the concomitant decrease in the number of medical residencies in the subspecialties. In 1990, there were 135 master's degree and 40 certificate NP programs. Between 1992 and 1994, the number of institutions offering NP education more than doubled, from 78 to 158. In 1994, most institutions offered several tracks, which led to a total of 384 NP tracks in master's programs throughout the United States. By 1998, the number of institutions offering NP education again doubled, representing a total of 769 distinct NP specialty tracks (AACN, 1999; NONPF, 1997). Most of these programs were at the master's or post-master's level. In 2013, the number of institutions offering a master's NP degree was 368, while 92 colleges offered a post-baccalaureate DNP NP (AACN, 2015). The NONPF has supported the concept of the DNP since its outset in 2002, and in 2015 it reaffirmed that support. The NONPF cautions, however, that it does not require NP educational programs to be at the doctoral level and indeed, in 2015, less than half of US NP programs were at that level (NONPF, 2015). Chapters 15 and 16 present discussions of NP roles. Meanwhile there has been rapid growth in the number of DNP programs nationwide. According to the DNP Directory, in 2017, there were 303 DNP programs, with more than 124 new programs in the planning stage (AACN, 2017). A survey commissioned by the AACN (2014) showed that about 70% of schools offering APRN education continue to only offer at the Master's of Science in Nursing (MSN) level and others continue to offer the MSN while also offering the DNP. Thus the master's degree remains the dominant form of APRN education. Conclusion Providing care to people in underserved areas has, by default, been assigned to nursing throughout the 20th and early 21st centuries. Moreover, history is clear that the concept of expanding the scope of practice for nurses was inextricably entwined with that assignment. HSS visiting nurses cared for poor immigrants of the Lower East Side unopposed by physicians until physicians perceived them as a threat. FNS nurses made diagnoses and treated patients in remote areas of Appalachia with the full approval of the physician committee who supervised them, and BIA nurses cured, as best they could, Native Americans in their communities. In other cases, if one considers time as place, so-called after midnight nurses expanded their scope of practice by defibrillating patients in CCUs across the nation, and army nurses did whatever needed to be done on the battlefield (Keeling, 2004). Only when APRNs threatened physicians' practice and income did organized medicine accuse them of practicing medicine without a license. Moreover, organized nursing itself was responsible for resisting the expansion of the scope of practice of nursing. However, it is also clear that when nurses and physicians focused on providing quality care for their patients, they were capable of working collaboratively and interdependently throughout the 20th century. Further analysis of the history of advanced practice nursing demonstrates the importance of evaluative research in documenting the contributions of APRNs to the health care system and patients' well-being. As evidenced by nurse anesthetist Alice Magaw's 1900 publication on outcomes, the early “APRNs” were particularly visionary in their use of data to document their effectiveness. Throughout the century, evaluative research based on measurable outcomes served as a tool for the profession to argue its position to health care policymakers and the medical profession (Brooten et al., 1986; Hamric, Lindbak, Jaubert, & Worley, 1998; Mitchell-DiCenso et al., 1996; Shah, Brutlomesso, Sullivan, & Lattanzio, 1997). As Beck (1995) stated, “It is inconsistent for a state medical association to maintain a position that quality health care is their objective … [while] … disregarding data demonstrating the positive impact of APNs on health care” (p. 15). The powerful influence of organizational efforts also emerges as a theme. National organization has been key to progress for advanced practice nursing, particularly in the realms of policy and regulation. Within the development of each of the advanced practice specialties, several common features have emerged. Strong national organizational leadership has been clearly demonstrated to be of critical importance in enhancing the growth and protection of the specialty. Based on the experience of the two oldest specialties, nurse anesthesia and nurse-midwifery, the process of establishing an effective national organization has taken a minimum of 3 decades. The history of these specialties reveals that specialty organizations have also played a critical role in the credentialing process for individuals in the specialty. The strength, unity, and depth of the organizational development of the two oldest advanced nursing specialties continue to serve as models for the younger developing specialties. An additional theme to emerge is the importance of professional unity regarding the requisite education of APRNs. Early in the 20th century, specialty education was considered to be postgraduate with a heavy component of on-the-job training; however, that education was commonly postdiploma, not postbaccalaureate, and did not result in a master's degree. These early programs were of variable length and quality. The establishment of credible and stable educational programs has been a crucial step in the evolution of advanced practice nursing. As educational programs moved from informal, institutionally based models with a strong apprenticeship approach to more formalized graduate education programs, the credibility of APRN roles has increased. State regulations also influenced the evolution of advanced practice as an increasing number of states mandated a master's degree as a prerequisite for APRN licensure. The influence of interprofessional struggles is apparent in all the advanced specialties, with the possible exception of the CNS. The legal battles between nursing and organized medicine are longstanding, particularly in relation to the nurse anesthesia, nursemidwifery, and nurse practitioner specialties. Most of these tensions have revolved around issues of control, autonomy, and economic competition. However, the issues are complex, with isolated examples of physician support of expanding nursing practice, such as physicians' support of early nurse anesthesia practice and Melzer's collaboration with Pinneo in expanding CCU nurse practice. In all, outcomes of the legal battles have mostly proven to be positive for nursing and have helped legitimize APRN roles. Nurse anesthetists, nurse-midwives, and NPs have specifically challenged the boundaries between nursing and medical practice. When they did, organized medicine responded and, today, these predictable responses should not be unexpected or underestimated. According to Inglis and Kjervik (1993), “It should be noted that organized medicine, largely through lobbying, has played a central role in creating and perpetuating the states' contradictory and constraining provisions of APRN practice” (p. 196). However, multiple national organizations and government entities have now called for the APRN to be effectively utilized, particularly since the passage of the Affordable Care Act (ANA, 2016). Controversy within the nursing community was also a strong theme as the specialties developed. CRNAs, and to some extent NPs, developed outside of mainstream nursing, whereas CNSs developed within the mainstream from the start. Nevertheless, each specialty has had to deal with resistance from other nurses. These intraprofessional struggles can be understood within the context of change—each of the APRN specialties represented innovations that challenged the status quo of the nursing establishment and the health care system. Throughout the 20th and early 21st centuries, prescriptive authority for advanced practice nursing, inextricably linked to economic and boundary issues between medicine and nursing, has been a particularly volatile legislative issue. Today, in most states, NPs, CNMs, and CRNAs can prescribe drugs with varying degrees of physician involvement and supervision. Although CNSs can prescribe in many states, they have not received the full recognition that has been granted to the other APRN groups. In 1997, Medicare expanded reimbursement for APRNs to all geographical and clinical settings, allowing direct Medicare reimbursement to 85% of the physician rate (AANP, 2013b). Thus, despite a great deal of progress in the roles of APRNs, specifically through the Consensus Model (Stanley, 2009), over the last century and gradual changes in state legislation and third-party reimbursement, APRNs have not reached their full potential to fulfill US health care needs. Barriers to enhancement of prescriptive authority for APRNs include the following: (1) exclusive reimbursement patterns, (2) anticompetitive practices and resistance of organized medicine, (3) and variable state regulation and practice acts (Beck, 1995; Keeling, 2007). Societal forces have clearly influenced the development of advanced practice nursing. Gender issues have affected all the specialties to some degree because of the unique position of nursing as a femaledominated profession. The specialties of nurse anesthesia and NP have been the exceptions, with more men entering these fields. Within nurse-midwifery, the status of women and women's health were powerful forces in the establishment and development of the specialty. The societal impact of war has served as a catalyst to the development of advanced practice nursing, education, and professional organizations. Finally, economic changes, particularly in relation to health care financing, have had a powerful effect on the development of advanced practice nursing. The dramatic growth of managed care systems in the 1990s, in particular, has presented new challenges and opportunities for APRNs related to reimbursement, scope of practice, and autonomy (Safriet, 1998). The Patient Protection and Affordable Care Act (2010) has led to more fundamental changes in health care financing and delivery and increased the need for APRN services (Lathrop & Hodnicki, 2014). With unremitting changes in nursing and health care, it is apparent that APRN specialties will continue to evolve and diversify. As new roles emerge, the history of advanced practice nursing continues to be written. Today, particularly in light of the DNP initiative, the profession is at a critical juncture at which it must decide whether it will mandate doctoral-level preparation for all APRN roles. While there is agreement on master's-level preparation for all APRNs, disagreements about the requirement of the doctorate (Cronenwett et al., 2011) may continue to impede progress on the adoption of standardized educational criteria in the future. Undoubtedly, as law professor Safriet (1998) has argued, consistency in the definition of advanced practice nursing and in the criteria for licensure as an APRN is critical to autonomy in practice. Thus what remains to be seen is whether the profession can unite on issues related to the definition of advanced practice nursing and standardized criteria for educational preparation to ensure that APRNs are permitted to practice with the autonomy experienced by other professionals. If that can be done, as the 2011 Institute of Medicine's The Future of Nursing report suggested, APRNs will make a significant contribution to the transformation of health care in the 21st century. Key Summary Points ▪ Throughout the 20th and 21st centuries, APRNs have provided care to the underserved poor, particularly in rural areas of the nation. However, when that care competes with physicians' reimbursement for their services, there has been significant resistance from organized medicine and their supporters in state legislative bodies, which results in interprofessional conflict. ▪ Documentation of the outcomes of practice helped establish the earliest nursing specialties and continues to be of critical importance to the survival of APRN practice. ▪ The efforts of national professional organizations, national certification, and the move toward graduate education as a requirement for advanced practice have been critical to enhancing the credibility of advanced practice nursing. For example, the move toward a DNP for APRNs has been highly successful. From an initial 2004 American Association of Colleges of Nursing position statement advancing the concept of a clinical doctorate for APRNs, there were, in 2016, almost 300 sites offering the DNP. ▪ Intraprofessional and interprofessional resistance to expanding the boundaries of the nursing discipline continues to occur. ▪ Societal forces, including wars, the economic climate, and health care policy, have influenced APRN history. References Adams Hampton I. Nursing. Its principles and practice for hospital and private use. Saunders: Philadelphia; 1893. American Association of Colleges of Nursing. Enrollment and graduations in baccalaureate and graduate programs in nursing. Author: Washington, DC; 1999. American Association of Colleges of Nursing. Essentials of doctoral education for advanced practice nursing. Author: Washington, DC; 2006. American Association of Colleges of Nursing. 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Spross, PhD, RN, FAAN, for her excellent work in previous editions. Concepts, models, and theories are used by advanced practice registered nurses (APRNs) to elicit histories, perform physicals, plan treatment, evaluate outcomes, and develop interpersonal relationships, as well as to help patients and families improve their health, cope with illnesses, and die with dignity. All APRNs, regardless of their years of experience and practice, rely on common processes and language to communicate with colleagues about patient care and to explain clinical situations. As such, it is important that the nursing profession and APRNs understand the language of advanced practice nursing to communicate it to each other, clients, and stakeholders. Understanding the conceptualization of advanced practice nursing, APRN practice, similarities and differences among APRNs, and how APRNs contribute to affordable, accessible, and effective care is central to actualizing a patient-centered, interprofessional health care system that maximizes patient outcomes and minimizes negative consequences. Conceptualizations of advanced practice nursing include models and theories that guide the practice of APRNs. The use of theory is fundamental to the sound progress in any practice discipline. Common language and mutually understood conceptual and theoretical frameworks support communication, guide practice, and are used to evaluate practice, education, policy, and research. Such a foundation is essential for APRNs given the proposed changes in the US health care system, as seen in the Patient Protection and Affordable Care Act (ACA) (2010), the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008), and The Future of Nursing (Institute of Medicine [IOM], 2011). Other forces driving a common understanding of APRNs are the increasing numbers of programs offering the Doctor of Nursing Practice (DNP) degree, accountable care organizations, and the promulgation of interprofessional competencies (Canadian Interprofessional Health Collaborative [CIHC], 2010; Health Professions Network Nursing and Midwifery Office, 2010; Interprofessional Education Collaborative [IPEC] Expert Panel, 2011), as well as recommendations to the US Congress to increase funding for interprofessional education and practice (National Advisory Council on Nurse Education and Practice, 2015). In addition to efforts in the United States, nursing associations, councils, and regulatory agencies in other countries have clarified, established, and/or regulated APRN roles and practice (Canadian Nurses Association [CNA], 2007, 2008, 2009a, 2009b; ICN Nurse Practitioner/Advanced Practice Nursing Network, 2016; International Council of Nurses [ICN], 2009; Nursing and Midwifery Board of Australia, 2014). In countries in which APRN roles exist, in addition to studies of the distinctions among roles (Gardner, Chang, Duffield, & Doubrovsky, 2013; Gardner, Duffield, Doubrovsky, & Adams, 2016; Lowe, Plummer, O'Brien, & Boyd, 2012), APRN educational programs are being established, for example, in Israel (Kleinpell et al., 2014), mainland China (Wong et al., 2010), and Singapore (National University of Singapore Yong Loo Lin School of Medicine, 2016). Country-specific frameworks are being developed to clarify education, scope of practice, registration and licensing, and/or credentialing (Fagerström, 2009). Although contextual factors may differ from those in the United States, global opportunities exist for clarifying and advancing APRN practice specific to a country's culture, health system, professional standards, and regulatory requirements. A sample of conceptual and theoretical models of APRN practice from various countries is presented in this chapter along with US and international conceptualizations of APRN roles. Professional organizations with interests in licensing, accreditation, certification, and educational (LACE) issues regarding APRNs also operate from a conceptualization of advanced practice nursing, whether implicit or explicit. In this chapter, models promulgated by APRN stakeholder organizations that describe the nature of advanced practice nursing and/or differentiate between advanced and basic practice, and selected models, including international, that have guided APRN practice are discussed. Problems associated with lack of a unified definition of advanced practice and imperatives for undertaking this important work exist. When practical, consensus on advanced practice nursing models should be beneficial for patients, society, and the profession. The APRN Consensus Model (APRN Joint Dialogue Group, 2008) and core competencies of APRN practice brought needed conceptual clarity to the regulation of advanced practice nursing in the United States. However, variations in scope of practice still remain between states in the United States (Pearson, 2014) and around the world (Kleinpell et al., 2014). Additionally, work is still needed to differentiate basic and advanced nursing practice and the practice of APRNs from that of other disciplines. Therefore the purposes of this chapter are as follows: 1. Lay the foundation for thinking about the concepts underlying advanced practice nursing by describing the nature, purposes, and components of conceptual models. 2. Identify conceptual challenges in defining and operationalizing advanced practice nursing. 3. Describe selected conceptualizations of advanced practice nursing. 4. Make recommendations for assessing existing models and developing, implementing, and evaluating conceptual frameworks for advanced practice. 5. Outline future directions for conceptual work on advanced practice nursing. It is important to note that, because of the dynamic and evolving nature of health care and nursing organizations activities in this arena, nationally and globally, readers are encouraged to consult the websites cited in this chapter for up-to-date information. Nature, Purposes, and Components of Conceptual Models A conceptual model is one part of the structure of nursing knowledge. Ranging from most abstract to most concrete, this structure consists of metaparadigms, philosophies, conceptual models, theories, and empirical indicators (Fawcett & Desanto-Madeya, 2013). Traditionally, key concepts in the metaparadigm of nursing are humans, the environment, health, and nursing (Fawcett & Desanto-Madeya, 2013). Fawcett and Desanto-Madeya (2013) described a conceptual model as “a set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe these concepts, and the propositions that state relatively abstract and general relations between two or more of the concepts” (p. 13). In addition, they noted that a conceptual model is “a distinctive frame of reference … that tells [adherents] how to observe and interpret the phenomenon of interest to the discipline” and “provide[s] alternative ways to view the subject matter of the discipline; there is no ‘best’ way” (p. 13). Although there is no best way to view a phenomenon, evolving a more uniform and explicit conceptual model of advanced practice nursing benefits patients, nurses, and other stakeholders (IOM, 2011) by facilitating communication, reducing conflict, and ensuring consistency of advanced practice nursing, when relevant and appropriate, across APRN roles, and by offering a “systematic approach to nursing research, education, administration, and practice” (Fawcett & Desanto-Madeya, 2013, p. 15). Models may help APRNs articulate professional role identity and function, serving as a framework for organizing beliefs and knowledge about their professional roles and competencies, providing a basis for further development of knowledge. In clinical practice, APRNs use conceptual models in the delivery of their holistic, comprehensive, and collaborative care (Carron & Cumbie, 2011; Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011; Elliott & Walden, 2015; Musker, 2011). Models may also be used to differentiate among and between levels of nursing practice—for example, between staff nursing and advanced practice nursing (Gardner et al., 2013) and between clinical nurse specialists (CNSs), nurse-midwives, and nurse practitioners (NPs) (Begley et al., 2013). Conceptual models are also used to guide research and theory development by focusing on a given concept or examining the relationships among select concepts to elucidate testable theories. For example, Gullick and West (2016) evaluated Wenger's Community of Practice framework to build research capacity and productivity for CNSs and NPs in Australia. Faculty, in the preparation of students for APRN roles, use conceptual models to plan curricula, to identify important concepts and their relationships, and to make choices about course content and clinical experiences (Perraud et al., 2006; Wong et al., 2010). Fawcett and Graham (2005) and Fawcett, Newman, and McAllister (2004) have challenged us to think about conceptual questions of advanced practice: • What do APRNs do that makes their practice “advanced”? • To what extent does incorporating activities traditionally done by physicians qualify nursing practice as “advanced”? • Are there nursing activities that are also advanced? Because direct clinical practice is viewed as the central APRN competency, this begs the question: What does the term clinical mean? Does it refer only to hospitals or clinics? These questions are becoming more important given the APRN Consensus Model and given the role that APRNs are expected to play across the continua of health care as a result of ongoing changes to health care legislation. From a regulatory standpoint, the emphasis on a specific population as a focus of practice will lead, when appropriate, to reconceptualizing curricula to ensure that graduates are prepared to succeed in new or revised certification examinations. Hamric and Tracy (see Chapter 3) have noted that although some APRN competencies (e.g., collaboration) may be performed by nurses in other roles, the expression of these competencies by APRNs is different. For example, although all nurses collaborate, a unique aspect of APRN practice is that APRNs are authorized to initiate referrals and prescribe treatments that are implemented by others (e.g., physical therapy). Innovations and reforms arising from changes in health care legislation will ensure that APRNs are explicitly engaged in the delivery of care across care settings, including in nursing clinics and palliative care settings, and as full participants in interprofessional teams. Changes in regulations and in the delivery of health care may be the impetus that leads to new or revised conceptualizations of advanced practice nursing (e.g., defining theoretical and evidencebased differences between the care provided by APRNs and other providers and clinical staff, the role of APRNs in interprofessional teams, and specialization and subspecialization in advanced practice nursing). Working together, nursing leaders and health policymakers will be able to design a health care system that delivers high-quality care at reasonable cost, based on disciplinary and interdisciplinary competencies, outcomes, effectiveness, efficacy, and efficacy. In addition to a pragmatic reevaluation of advanced practice nursing concepts based on the evolution of APRN regulation and health care reform, important theoretical questions are being raised about the conceptualization of advanced practice nursing. Issues range from the epistemologic, philosophical, and ontologic underpinnings of advanced practice (Arslanian-Engoren, Hicks, Whall, & Algase, 2005) and the extent to which APRNs are prepared to apply nursing theory to their practices (Algase, 2010; ArslanianEngoren et al., 2005; Karnick, 2011) to the questions about the nature of advanced practice knowledge, discerning the differences between and among the notions of specialty, advanced practice, and advancing practice (Allan, 2011; Christensen, 2009, 2011; MacDonald, Herbert, & Thibeault, 2006; Thoun, 2011). In summary, questions arising from a changing health policy landscape and from theorizing about advanced practice nursing underscore the need for well thought-out, robust conceptual models to guide APRN practice. Conceptual clarity of advanced practice nursing, what it is and is not, is important not only for patients and those in the nursing profession but also for interprofessional education (CIHC, 2010; Health Professions Network Nursing and Midwifery Office, 2010; IPEC Expert Panel, 2011) and practice (American Association of Nurse Anesthetists [AANA], 2012). Conceptual clarity of advanced practice nursing will also inform the creation of accountable care organizations and support efforts to build teams and systems in which effective communication, collaboration, and coordination will lead to high-quality care and improved patient, institutional, and fiscal outcomes. Conceptualizations of Advanced Practice Nursing: Problems and Imperatives Despite the usefulness and benefits of conceptual models, conceptual confusion and uncertainty remain regarding advanced practice nursing. One noted issue is the lack of a well-defined and consistently applied core stable vocabulary used for model building. Despite progress, this challenge remains. For example, in the United States advanced practice nursing is the term that is used, but the ICN and CNA use the term advanced nursing practice. Considerable variation is noted between the conceptual definition of advanced practice nursing and that of advanced nursing practice as used in Australia, Canada, New Zealand, the United States, Canada, and the United Kingdom (Stasa, Cashin, Buckley, & Donoghue, 2014). Adding to this opacity is the use of the term advanced practitioner to describe the role of non-APRN experts in the United Kingdom and internationally (McGee, 2009). The role and functions of APRNs need to be clearly and consistently conceptualized. The APRN Consensus Model (APRN Joint Dialogue Group, 2008) represents a major step forward in promulgating a uniform definition of advanced practice in the United States, for the purpose of regulation. However, the lack of a core vocabulary continues to make comparisons difficult because the conceptual meanings vary. Competencies are more commonly used to describe concepts of APRN practice, but reflection on and discussion of other terms such as roles, hallmarks, functions, activities, skills, and abilities continue and may contribute to the urgent need for clarification of conceptual models and a common language. Few models of APRN practice address nursing's metaparadigm (person, health, environment, nursing) comprehensively. The problem in comparing, refining, or developing models is that concepts are often used without universal meaning or consensus and, occasionally, with no or inconsistent definitions. It is rightly anticipated that conceptual models of the field and its practice change over time. However, the evolution of advanced practice nursing and its comprehension by nurses, policymakers, and the public will be enhanced if scholars and practitioners agree on the use and definition of fundamental concepts of APRN practice. Another challenge is the paucity of conceptual models describing the practice and outcomes of APRNs. Although the numbers of models are increasing, they remain small. Further compounding this issue is the scarcity of international and global models of APRN practice. Models are needed that address the diverse health and cultural needs of individuals, families, and communities worldwide. Another issue is a lack of clarity in the conceptualizations that differentiate the clinical practice of APRNs from that of registered nurses (RNs) without graduate degrees in advanced practice. Conceptual models can help to identify key concepts and variables that distinguish the focus, levels of practice, and outcomes between and among nurses with different levels and types of academic preparation and specialty certification. Of additional importance is clarifying and distinguishing the differences in practice of APRNs and physician colleagues. Some graduate APRN students may struggle with this issue as part of role development. The lack of conceptual clarity is apparent in advertisements that invite both NPs and physician assistants to apply for the same position. Organized medicine continues to expend resources trying to limit or discredit advanced practice nursing, even as some physician leaders work on behalf of advocating for APRNs. Barriers to APRNs' ability to practice to the full extent of their education and training as recommended by the IOM (2011) may be the result of lack of conceptual clarity between nursing at the advanced practice level and the practice of medicine. To this end, the philosophical underpinnings of conceptual models of APRN practice need explication. The emphasis on interprofessional education and practice is another issue in need of clarification. Interprofessional education and practice is central to accountable, collaborative, coordinated, and high-quality care. Graduate education of APRNs alongside other health professionals is beginning to take place. For example, at the University of Michigan, an interprofessional clinical decision-making course with graduate students from nursing (APRN students), pharmacy, dentistry, medicine, and social work is one of the first of its kind in the nation. Students learn together and from each other about their roles, preparation, and disciplinary foci (Sweet, Madeo, Fitzgerald, et al., 2017). The development of interprofessional competencies for health professionals (CIHC, 2010; Health Professions Network Nursing and Midwifery Office, 2010; IPEC Expert Panel, 2011) indicates the need for high-functioning, interprofessional teams of health care experts to maximize patient outcomes. The existence of interprofessional competencies and emergence of promising conceptualizations of interprofessional work are critical contextual factors for elucidating and advancing conceptualizations of advanced practice nursing (Barr, Freeth, Hammick, Koppel, & Reeves, 2005; Reeves et al., 2011). Conceptual models for APRN practice on interprofessional teams are needed to explicate the unique and critical contributions of APRNs to patient outcomes and system resources. Among many imperatives for reaching a conceptual consensus on advanced practice nursing, most important are the interrelated areas of policymaking, licensing and credentialing, and practice, including competencies. In the policymaking arena, for example, not all APRNs are eligible to be reimbursed by insurers, and even those activities that are reimbursable are often billed incident to a physician's care, rendering the work of APRNs invisible. The APRN Consensus Model (APRN Joint Dialogue Group, 2008), the ACA (2010), and the IOM's call for changes to enable APRNs to work within their full scope of practice (IOM, 2011) will make it easier for US policymakers to recommend and adopt changes to policies and regulations that now constrain APRN practice, eventually making the contributions of APRNs to quality care visible and reimbursable. Agreement on vocabulary and concepts such as competencies that are common to all APRN roles will maximize the ability of APRNs to work within their full scope of practice. Although some progress has been made, there are compelling reasons for continuing dialogue and activity aimed at clarifying advanced practice nursing and the concepts and models that help stakeholders understand the nature of APRN work and the contributions of APRNs. Reaching consensus on concepts and vocabulary will serve theoretical, practical, and policymaking purposes. As the work of health care reform and implementing interprofessional competencies, education, and practice moves forward, there will be opportunities for the profession to conceptualize advanced practice nursing more clearly. Box 2.1 presents outcomes that come from clarification and consensus on conceptualization of the nature of advanced practice nursing. Box 2.1 Clarification and Consensus on Conceptualization of the Nature of Advanced Practice Nursing 1. Clear differentiation of advanced practice nursing from other levels of clinical nursing practice. 2. Clear differentiation between advanced practice nursing and the clinical practice of physicians and other non-nurse providers within a specialty. 3. Clear understanding of the roles and contributions of advanced practice registered nurses (APRNs) on interprofessional teams, enabling employers to create teams and accountable care organizations that can meet institutions' clinical and fiduciary outcomes. 4. Clear delineation of the similarities and differences among APRN roles and the ability to match APRN skills and knowledge to the needs of patients. 5. Regulation and credentialing of APRNs that protect the public and ensure equitable treatment of all APRNs. 6. Clear articulation of international, national, state, and local health policies that do the following: a. Recognize and make visible the substantive contributions of APRNs to quality, cost-effective health care and patient outcomes. b. Ensure the public's access to APRN care. c. Ensure explicit and appropriate mechanisms to bill and pay for APRN care. 7. A maximum social contribution by APRNs in health care, including improvement in health outcomes and healthrelated quality of life for the people to whom they provide care. 8. The actualization of practitioners of advanced practice nursing, enabling APRNs to reach their full potential, personally and professionally. Conceptualizations of Advanced Practice Nursing Roles: Organizational Perspectives Practice with individual clients or patients is the central work of the field; it is the reason for which nursing was created. The following questions are the kinds of questions a conceptual model of advanced practice nursing should answer: • What is the scope and purpose of advanced practice nursing? • What are the characteristics of advanced practice nursing? • Within what settings does this practice occur? • How do APRNs' scopes of practice differ from those of other providers offering similar or related services? • What knowledge and skills are required? • How are these different from those of other providers? • What patient and institutional outcomes are realized when APRNs deliver care? How are these outcomes different from those of other providers? • When should health care systems employ APRNs, and what types of patients particularly benefit from APRN care? • For what types of pressing health care problems are APRNs a solution in terms of improving outcomes, quality of care, and cost-effectiveness? Of the conceptual models presented in this chapter, some are more narrowly focused than others, and some are more homogeneous or mixed with respect to the phenomenon studied. Models may be seen as micromodels in terms of the unit of analysis or as metamodels incorporating a number of conceptual frameworks. Still other models explain systems and the relationships between and among systems. All these foci are important, depending on the purposes to be served. However, in the development of conceptual models, the phenomenon to be modeled must be carefully defined. For example, a model may encompass the entire field of advanced practice nursing or be confined to distinctive concepts (e.g., collaborative practice between APRNs and physicians or the difference between APRN practice and the practice of non-APRN nurses). If a phenomenon and its related concepts are not clearly defined, the model could be so inconsistent as to be confusing or so broad that its impact will be diluted. In addition to describing concepts and how they are related, assumptions about the philosophy, values, and practices of the profession should be reflected in conceptual models. The discussion of conceptualizations of advanced practice nursing is guided by these assumptions: 1. Each model, at least implicitly, addresses the four elements of nursing's metaparadigm: persons, health and illness, nursing, and the environment. 2. The development and strengthening of the field of advanced practice nursing depends on professional agreement regarding the nature of advanced practice nursing (a conceptual model) that can inform APRN program accreditation, credentialing, and practice. 3. APRNs meet the needs of society for advanced nursing care. 4. Advanced practice nursing will reach its full potential to the extent that foundational conceptual components of any model of advanced practice nursing framework are delineated and agreed on. Consensus Model for Advanced Practice Registered Nurse Regulation In 2004, an APRN Consensus Conference was convened to achieve consensus regarding the credentialing of APRNs (APRN Joint Dialogue Group, 2008; Stanley, Werner, & Apple, 2009) and the development of a regulatory model for advanced practice nursing. Independently, the APRN Advisory Committee for the National Council of State Boards of Nursing (NCSBN) was charged by the NCSBN Board of Directors with a similar task of creating a future model for APRN regulation and, in 2006, disseminated a draft of the APRN Vision Paper (NCSBN, 2006), a document that generated debate and controversy. Within a year, these groups came together to form the APRN Joint Dialogue Group, with representation from numerous stakeholder groups, and the outcome was the APRN Consensus Model (APRN Joint Dialogue Group, 2008). The APRN Consensus Model includes important definitions of roles, titles, and population foci. Furthermore, it defines specialties and describes how to make room for the emergence of new APRN roles and population foci within the regulatory framework. A timeline for adoption and strategies for implementation were put forth, and progress has been made in these areas (see Chapter 22 for further information; only the model is discussed here). Fig. 2.1 depicts the components of the APRN Consensus Model, the four recognized APRN roles and six population foci. The term advanced practice registered nurse refers to all four APRN roles. An APRN is defined as a nurse who meets the following criteria (APRN Joint Dialogue Group, 2008): FIG 2.1 Consensus model for APRN regulation. This model was based on the work of the APRN Consensus Work Group and the NCSBN APRN Advisory Committee. (From APRN Joint Dialogue Group. [2008]. Consensus model for APRN regulation. Retrieved from http://www.aacn.nche.edu/education-resources/APRNReport.pdf.) *The population focus Adult-Gerontology encompasses the young adult to the older adult, including the frail elderly. APRNs educated and certified in the Adult-Gerontology population are educated and certified across both areas of practice and will be titled Adult-Gerontology CNP or CNS. In addition, all APRNs in any of the four roles providing care to the adult population (e.g., Family or Gender Specific) must be prepared to meet the growing needs of the older adult population. Therefore the education program should include didactic and clinical education experiences necessary to prepare APRNs with these enhanced skills and knowledge. †The clinical nurse specialist (CNS) is educated and assessed through national certification processes across the continuum from wellness through acute care. ‡The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the primary care CNP competencies. At this point in time the acute care and primary care CNP delineation applies only to the Pediatrics and Adult-Gerontology CNP population foci. Scope of practice of the primary care or acute care CNP is not setting-specific but is based on patient care needs. Programs may prepare individuals across both the primary care and acute care CNP roles. If programs prepare graduates across both roles, the graduate must be prepared with the consensusbased competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. • Completes an accredited graduate-level education program preparing him or her for one of the four recognized APRN roles and a population focus (see discussion in Chapter 3) • Passes a national certification examination that measures APRN role and population-focused competencies and maintains continued competence by national recertification in the role and population focus • Possesses advanced clinical knowledge and skills preparing him or her to provide direct care to patients; the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals • Builds on the 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 role autonomy • Is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance, as well as the assessment, diagnosis, and management of patient problems, including the use and prescription of pharmacologic and nonpharmacologic interventions • Has sufficient depth and breadth of clinical experience to reflect the intended license • Obtains a license to practice as an APRN in one of the four APRN roles The definition of the components of the APRN Consensus Model begins to address some of the questions about advanced practice posed earlier in this chapter. An important agreement was that providing direct care to individuals is a defining characteristic of all APRN roles. This agreement affirms a position long held by original and current editors of this text—that when there is no direct practice component in the role, one is not practicing as an APRN. It also has important implications for LACE and for career development of APRNs. Graduate education for the four APRN roles is described in the Consensus Model document. It must include completion of at least three separate, comprehensive graduate courses in advanced physiology and pathophysiology, physical health assessment, and advanced pharmacology (the “three Ps”), consistent with requirements for the accreditation of APRN education programs. In addition, curricula must address three other areas—the principles of decision making for the particular APRN role, preparation in the core competencies identified for the role, and role preparation in one of the six population foci. The Consensus Model asserts that licensure must be based on educational preparation for one of the four existing APRN roles and a population focus, that certification must be within the same area of study, and that the four separate processes of LACE are necessary for the adequate regulation of APRNs (APRN Joint Dialogue Group, 2008; see Chapter 22). The six population foci displayed in Fig. 2.1 include the individual and family across the life span as well as adult/gerontologic, neonatal, pediatric, women's health/gender- specific, and psychiatric/mental health populations. Preparation in a specialty, such as oncology or critical care, cannot be the basis for licensure. Specialization “indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty area could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations)” (APRN Joint Dialogue Group, 2008, p. 12). This was a critical decision for the group to reach, given the numbers of specialties and APRN specialty examinations in place when the document was prepared. Even with this brief overview of the APRN Consensus Model, one sees how this model advanced the conceptualization of advanced practice nursing. It is helpful for many reasons. First, for the United States, it affirms that there are four APRN roles. Second, it is advancing a uniform approach to LACE and advanced practice nursing that has practical and policymaking effects, including better alignment between and among APRN curricula and certification examinations. Furthermore, it addresses the issue of differentiating between RNs and APRNs and has been foundational to differentiate among nursing roles. By addressing the issue of specialization, the model offers a reasoned approach for the following: (1) avoiding confusion from a proliferation of specialty certification examinations; (2) ensuring that, because of a limited and parsimonious focus (four roles and six populations), there will be sufficient numbers of APRNs for the relevant examinations to ensure psychometrically valid data on test results; and (3) allowing for the development of new APRN roles or foci to meet society's needs. Although there are a number of noted strengths of the Consensus Model, there are also limitations. First, competencies that are common across APRN roles are not addressed beyond defining an APRN and indicating that students must be prepared “with the core competencies for one of the four APRN roles across at least one of the six population foci” (APRN Joint Dialogue Group, 2008, p. 10). The model leaves it to the different APRN roles to develop their own core competencies. In addressing specialization, the model also leaves open the issue of the importance of educational preparation, in addition to experience, for advanced practice in a specialty. Two years after the 2004 APRN consensus conference, the American Association of Colleges of Nursing (AACN, 2006) put forth the Essentials of Doctoral Education for Advanced Nursing Practice. The Essentials established the DNP, the highest practice degree and the preferred preparation for specialty nursing practice. The AACN called for doctorate-level preparation of APRNs by the year 2015. DNP preparation for entry to practice has been endorsed by the AANA (2007), the National Association of Clinical Nurse Specialists (2015), and the National Organization of Nurse Practitioner Faculties (NONPF, 2015). However, the American College of Nurse-Midwives (ACNM, 2015) has not endorsed the DNP as a requirement for entry into practice for CNMs, instead supporting the completion of a graduate degree program requirement for certification and entry into clinical practice. Although experience in an area is certainly a factor that leads to the emergence of new specialties, experience alone may be insufficient for the APRN who specializes in oncology or critical care (or another specialty) to achieve desired outcomes in timely and cost-effective ways. These are specialties in which the population's needs are many and complex and the scope of research knowledge is similarly broad and deep. These are important areas of conceptualization that need to be addressed by the American Nurses Association (ANA) and specialty professional nursing organizations, rather than by a group with a regulatory focus. Numerous efforts are underway to implement this model in the United States. The NCSBN has an extensive toolkit to help educators, APRNs, and policymakers implement the new APRN regulatory model (NCSBN, 2015). The work undertaken to produce the APRN Consensus Model (APRN Joint Dialogue Group, 2008) illustrates the power of interorganizational collaboration and is a promising example of how a model can, as Fawcett and Desanto-Madeya (2013) have suggested, reduce conflict and facilitate communication within the profession, across professions, and with the public. American Nurses Association As the only full-service professional organization representing the interests of the 3.6 million RNs in the United States through its constituent and state nurses associations and its organizational affiliates, the ANA and its constituent organizations have also been active in developing documents that address advanced practice nursing. Two of these are particularly important for the contemporary conceptualizations of advanced practice nursing. Since 1980, the ANA has periodically updated its Social Policy Statement (ANA, 2010b). Specialization has consistently been identified as a concept that differentiates advanced practice nursing from basic nursing practice. The most recent edition of the policy notes that specialization (“focusing on nursing practice in a specific area, identified from within the whole field of professional nursing”; ANA, 2010b, p. 17) can occur at basic or advanced levels and that APRNs use additional specialized knowledge and skills obtained through graduate education in their practices. According to this statement, advanced nursing practice “builds on the competencies of the registered nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education” (ANA, 2010b, p. 18). In this document, APRNs are defined as RNs who hold master's or doctoral degrees and are licensed, certified, and/or approved to practice in their roles by state boards of nursing or regulatory oversight bodies. APRNs are prepared through graduate education in nursing for one of four APRN roles (NPs, certified registered nurse anesthetists [CRNAs], NMs, CNSs) and at least one of six population foci (family/individual across the life span, adult/gerontology, neonatal, pediatrics, women's health/gender-related health, psychiatric/mental health) (ANA, 2010b). These definitions of specialization and advanced practice are consistent with the APRN Consensus Model. The ANA also establishes and promulgates standards of practice and competencies for RNs and APRNs. Six standards of practice and 10 standards of professional performance are described in the second edition of Nursing: Scope and Standards of Practice (ANA, 2010a). Each standard is associated with competencies. Of the 16 total standards, all but one (Standard 11, “Communication”) outlines additional competencies for APRNs compared with RNs. For example, Standard 5, “Implementation,” addresses the consultation and prescribing responsibilities of APRNs and Standard 12, “Leadership,” addresses the mentoring and role development responsibilities of APRNs. It is in the description of the competencies that APRN practice and the practice of nurses prepared in a specialty at the graduate level are differentiated from RN practice. In addition to these documents, the ANA, together with the American Board of Nursing Specialties (ABNS), convened a task force on Clinical Nurse Specialist competencies. For many reasons, including the recognition that developing psychometrically sound certifications for numerous specialties, especially for CNSs, would be difficult as the profession moved toward implementing the APRN Consensus Model, the ANA and ABNS convened a group of stakeholders in 2006 to develop and validate a set of core competencies that would be expected of CNSs entering practice, regardless of specialty (National Association of Clinical Nurse Specialists [NACNS]/National CNS Core Competency Task Force, 2010). This work is discussed later in this chapter in the section on the NACNS. American Association of Colleges of Nursing Over the last decade, the AACN has undertaken two nursing education initiatives aimed at transforming nursing education. In 2006, the AACN called for APRN preparation to be at the doctoral level in practice-based programs (DNP), with master's level education being refocused on generalist preparation (e.g., clinical nurse leaders, staff, and clinical educators). Clinical nurse leaders are not APRNs (AACN, 2005, 2012; Spross et al., 2004) and therefore are not included in this discussion of conceptualizations. Through these initiatives, and to the extent that the AACN and Commission on Collegiate Nursing Education influence accreditation, the DNP is becoming the preferred degree for most APRNs. The growth of DNP education has advanced considerably. In 2006, there were 20 DNP programs; in 2016, there were 289, with an additional 128 DNP programs in the planning stage (AACN, 2015). Enrollments in and graduation from DNP programs have also risen substantially (AACN, 2016). The DNP Essentials (AACN, 2006) are composed of eight competencies for DNP graduates (Box 2.2). For APRNs, “Essential VIII specifies the foundational practice competencies that cut across specialties and are seen as requisite for DNP practice” (AACN, 2006, p. 16; see Box 2.3). Recognizing that DNP programs also prepare nurses for non-APRN roles, the AACN acknowledged that organizations representing APRNs are expected to develop Essential VIII as it relates to specific advanced practice roles and to “develop competency expectations that build upon and complement DNP Essentials 1 through 8” (AACN, 2006, p. 17). These Essentials affirm that the advanced practice nursing core includes the “three Ps” (three separate courses)—advanced health/physical assessment, advanced physiology/pathophysiology, and advanced pharmacology—and is specific to APRNs. The specialty core must include content and clinical practice experiences that help students acquire the knowledge and skills essential to a specific advanced practice role. These requirements were reconfirmed in the Consensus Model (APRN Joint Dialogue Group, 2008). Box 2.2 Essentials of Doctoral Education for Advanced Nursing Practice I. Scientific underpinnings for practice II. Organizational and systems leadership for quality improvement and systems thinking III. Clinical scholarship and analytical methods for evidencebased practice IV. Information systems and technology and patient care technology for the improvement and transformation of health care V. Health care policy for advocacy in health care VI. Interprofessional collaboration for improving patient and population health outcomes VII. Clinical prevention and population health for improving the nation's health VIII. Advanced nursing practice From American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf. Box 2.3 Essential VIII: Advanced Nursing Practice Competencies 1. Conduct a comprehensive and systematic assessment of health and illness parameters in complex situations, incorporating diverse and culturally sensitive approaches. 2. Design, implement, and evaluate therapeutic interventions based on nursing science and other sciences. 3. Develop and sustain therapeutic relationships and partnerships with patients (individual, family, or group) and other professionals to facilitate optimal care and patient outcomes. 4. Demonstrate advanced levels of clinical judgment, systems thinking, and accountability in designing, delivering, and evaluating evidence-based care to improve patient outcomes. 5. Guide, mentor, and support other nurses to achieve excellence in nursing practice. 6. Educate and guide individuals and groups through complex health and situational transitions. 7. Use conceptual and analytical skills in evaluating the links among practice, organizational, population, fiscal, and policy issues. From American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice (pp. 16–17). Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf. The DNP has been described as both a “disruptive innovation” (Hathaway, Jacob, Stegbauer, Thompson, & Graff, 2006) and a natural evolution for NP practice. The DNP has been endorsed as entry for APRN practice by three of the four professional association/organizations representing APRNs, with the exception of the ACNM (2015). As a result of national DNP discussions, APRN organizations have promulgated practice competencies for doctorally prepared APRNs (e.g., ACNM, 2011c; CNS Practice Doctorate Competencies Taskforce of the NACNS, 2009). The NONPF (2012) now has one set of core competencies for NPs. Organizational positions on doctoral education are briefly explored in the discussion of APRN organizations later in this chapter. Although not a conceptual model per se, the AACN's publication The Essentials of Doctoral Education for Advanced Nursing Practice (2006) addresses concepts and content now evident in other documents that address standards of APRN practice and education. The fact that Essential VIII affirms a set of common competencies across APRN roles is an important contribution to conceptual clarity about advanced practice in the United States. Because these Essentials, with the exception of Essential VIII, are intended to address DNP preparation for any nursing role, the contribution of this document to conceptual clarity regarding advanced practice nursing specifically is limited, and its broad definition can lead to further confusion. With the evolution of the DNP, more conceptual clarity may be gained regarding advanced practice nursing and the role of APRNs. However, it is possible that the rapid expansion of this degree will contribute to less clarity in the short term about the nature of advanced nursing practice and the centrality of direct care of patients to APRN work, particularly because the DNP will also prepare nurses for other, nonclinical nursing roles. A discussion of APRN organizations' conceptualization of APRN practice follows, along with a discussion of the extent to which their responses to the DNP influence conceptual clarity on advanced practice nursing. National Organization of Nurse Practitioner Faculties The mission of the NONPF is to provide leadership in promoting quality NP education. Since 1990, the NONPF has fulfilled this mission in many ways, including the development, validation, and promulgation of NP competencies. As of 2012, there is only one set of NP core competencies (NONPF, 2012). A brief history of the development of competencies for NPs is presented here, in part because their development has influenced other APRN models. In 1990, the NONPF published a set of domains and core competencies for primary care NPs based on Benner's (1984) domains of expert nursing practice and the results of Brykczynski's (1989) study of the use of these domains by primary care NPs (Price et al., 1992; Zimmer et al., 1990). Within each domain were a number of specific competencies that served as a framework for primary care NP education and practice. After endorsing the DNP as entry-level preparation for the NP role, and consistent with the recommendations in the APRN Consensus Model (APRN Joint Dialogue Group, 2008), new NP core competencies were developed in 2011 and amended in 2012, with core competency content developed in 2014 (NONPF, 2011, 2012, 2014). Each of the nine core competencies is accompanied by specific behaviors that all graduates of NP programs, whether master's or DNP prepared, are expected to demonstrate. Population-specific competencies for specific NP roles, together with the nine core competencies, are intended to inform curricula and ensure that graduates will meet certification and regulatory requirements. From a conceptual perspective, these NP core and populationspecific competency documents are notable for several reasons: (1) the competencies for NPs were developed collaboratively by stakeholder organizations; (2) empirical validation is used to affirm the competencies; (3) overall, the competencies are conceptually consistent with statements in the APRN Consensus Model, the DNP Essentials (AACN, 2006), and the ANA's Nursing: Scope and Standards of Practice (ANA, 2010a); and (4) the revised competencies are responsive to society's needs for advanced nursing care and the contextual factors that will shape NP practice for at least the next decade. In the amended 2011 NONPF competencies (NONPF, 2011, 2012), there is an emphasis on practice that is not in the APRN Consensus Model (APRN Joint Dialogue Group, 2008)—patientcentered care, interprofessional care, and independent or autonomous NP practice, clearly responsive to health care reform initiatives, are addressed. National Association of Clinical Nurse Specialists The NACNS published the Statement on Clinical Nurse Specialist Practice and Education in 1998, revised it in 2004, and is currently working on the next iteration, which is not yet published at the time of this chapter. Although acknowledging the early conceptualization of CNS practice as subroles proposed by Hamric and Spross (1983, 1989), this conceptualization failed to adequately differentiate CNS practice from that of other APRNs. The NACNS statement was put forth to resolve the ambiguity about this foundational APRN role. Three spheres of influence are posited: patient, nurses and nursing practice, and organization or system, each of which requires a unique set of competencies (NACNS, 2004; see Fig. 2.2). The statement also outlined expected outcomes of CNS practice for each sphere and competencies that parallel those of the nursing process. Thus CNSs have spherespecific competencies of assessment, diagnosis, intervention, and evaluation. FIG 2.2 National Association of Clinical Nurse Specialists model. CNS practice conceptualized as core competencies in three interacting spheres is shown, as actualized in specialty practice and guided by specialty knowledge and standards. The reader should note that this model predates the Consensus Model of APRN Regulation and the definitions of specialization and population foci in the Consensus Model. (From National Association of Clinical Nurse Specialists. [2004]. Statement on clinical nurse specialist practice and education [2nd ed.]. Harrisburg, PA: Author.) As work on the APRN Consensus Model neared completion, the NACNS and the APRN Consensus Work Group asked the ANA and the ABNS to “convene and facilitate the work of a National CNS Competency Task Force,” using a standard process to develop nationally recognized education standards and competencies (NACNS/National CNS Competency Task Force, 2010, p. 3). The process of developing and validating the competencies is described in the document. Fig. 2.3 illustrates the model of CNS competencies that emerged from this work, a synthesis of the NACNS' spheres of influence, Hamric's seven advanced practice nursing competencies, and the Synergy model. Subsequently, new criteria for evaluating CNS education programs were developed, based on the competencies (Validation Panel of the NACNS, 2011). The APRN Consensus Model has impacted certification for CNS roles more than any other APRN role. FIG 2.3 NACNS model of CNS competencies. (From National Association of Clinical Nurse Specialists/National CNS Competency Task Force. [2010]. Clinical nurse specialist core competencies: Executive summary 2006–2008. Retrieved from http://www.nacns.org/docs/CNSCoreCompetenciesBroch.pdf.) The 2004 statement and the new CNS competencies are not entirely parallel. Some aspects of the 2004 statement were more comprehensive with regard to theoretical elements (e.g., inclusion of assumptions and theoretical roots in nursing). The 2010 document has an appendix that includes definitions of key concepts (e.g., nurses and nursing practice, spheres of influence, and competencies). An underlying assumption of these core competencies, which has empirical validation (e.g., Lewandowski & Adamle, 2009), is that CNSs have an impact on patients, nursing practice, and organizational outcomes. From a conceptual standpoint, the CNS competencies document brought needed clarity on several fronts: (1) ensuring that all CNSs would be eligible for credentialing under the APRN Consensus Model so that CNSs could take a psychometrically valid examination on their core competencies, because examinations could not be developed for every existing area of specialization; (2) advancing the work of the NACNS in ensuring consistency among programs preparing CNSs; and (3) because CNSs' work often looks very different from that of other APRNs (e.g., fewer responsibilities for prescribing but more responsibilities for clinical and systems leadership), facilitating the profession's ability to speak about what is common across APRN roles. At least two areas will need further clarification. One is the relationship between the 2004 statement and the 2010 competencies, because both documents are available and CNS authors still refer to the 2004 statement. Both are being used, which is understandable; there is content in the statement that is not in the new competencies document, including, in addition to the 2004 competencies, relevant history, a description of CNS practice, and recommendations for graduate programs. The second area will be the ongoing need for clarity regarding specialty as defined in the Consensus Model (the population focus, not specialization, is the basis for regulation). From a regulatory standpoint, it would seem that a CNS's specialty is his or her population focus as defined in the Consensus Model. Initially the NACNS published a white paper describing a position of neutrality regarding the DNP as an option for CNS education (NACNS, 2005). However, the NACNS did develop core competencies for doctoral-level practice, recognizing that some CNSs would pursue advanced clinical doctorates (CNS Practice Doctorate Competencies Taskforce of the NACNS, 2009). Three years later, the NACNS (2012) published a Statement on the APRN Consensus Model Implementation, outlining the importance of grandfathering currently practicing CNSs and monitoring the implementation of the Consensus Model to ensure that its adoption would not negatively affect the ability of CNSs to practice. In June of 2015, the NACNS issued a position statement endorsing the DNP as entry into practice for CNSs by 2030. Within this position statement, the NACNS stated support for “CNSs who pursued other graduate education to retain their ability to practice within the CNS role without having to obtain the DNP for future practice as an APRN after 2030” (NACNS, 2015, p. 2). For further information, see the NACNS website and Chapter 14. American Association of Nurse Anesthetists CRNAs are recognized as APRNs within the APRN Consensus Model. Advanced practice competencies, as described in the DNP Essentials (AACN, 2006), the ANA Scope and Standards (ANA, 2010a), and the APRN competencies identified in this text, are evident in the official statements of the AANA (2010, 2013a, 2013b). These statements include scopes of practice, standards for practice, and ethics. Chapter 18 provides a thorough discussion of CRNA practice. The CRNA's scope and standards of practice are defined in two separate documents from the AANA: Scope of Nurse Anesthesia Practice (2013a) and Standards for Nurse Anesthesia Practice (2013b). The Scope of Nurse Anesthesia Practice addresses the responsibilities of CRNAs performed in collaboration with other qualified health care providers, while the Standards for Nurse Anesthesia Practice describe the minimum rules and responsibilities of professional CRNA practice. The Scope document addresses the professional role; education, accountability and leadership; anesthesia practice; and the value and future of nurse anesthesia practice. The purposes of the 11 Standards are to: (1) assist the profession in evaluating CRNA care, (2) provide a common foundation on which CRNAs can develop a quality practice, (3) help the public understand what they can expect from CRNAs, and (4) support and preserve the basic rights of patients. The Scope of Nurse Anesthesia Practice and Standards for Nurse Anesthesia Practice provide descriptions that can be characterized as clinical competencies or responsibilities (e.g., managing a patient's airway)—the direct clinical practice of CRNAs. Initially, the AANA did not support the DNP for entry into CRNA practice and established a task force to evaluate doctoral preparation further. Subsequently, the AANA issued a position statement (2007) requiring doctoral preparation for nurse anesthesia practice by the year 2025. However, the position statement does not specify the type of doctoral degree. This likely reflects the diversity of existing practice doctorates for nurse anesthesia practice in addition to the DNP, such as Doctor of Nurse Anesthesia Practice and Doctor of Management of Practice in Nurse Anesthesia (Dreher, 2011; Hawkins & Nezat, 2009). In 2015, the Council on Accreditation of Nurse Anesthesia Educational Programs revised its 2004 accreditation standards for nurse anesthesia education. Notably, the standards include a requirement for the “three P” courses, consistent with requirements specified in the APRN Consensus document. The standards also distinguish between competencies expected for graduates of a practice doctorate program (referencing both the DNP and the Doctor of Nurse Anesthesia Practice as examples) and research-oriented doctorate programs (e.g., Ph.D.). In addition, accreditation standards have been developed for the practice doctorate in nurse anesthesia (Council on Accreditation of Nurse Anesthesia Educational Programs, 2015). Competencies within these documents align with those in the DNP Essentials (AACN, 2006), referred to as “commonly accepted national standards.” American College of Nurse-Midwives Certified nurse-midwives (CNMs) are APRNs who are recognized in the APRN Consensus Model. Advanced practice competencies, described in the DNP Essentials (AACN, 2006), the ANA Scope and Standards (ANA, 2010a), and the APRN competencies are apparent in the official statements of the ACNM (2011a, 2011b). These statements include scopes of practice, standards for practice, and ethics. Chapter 17 presents a thorough discussion of CNM practice. The scope of practice for CNMs (and certified midwives [CMs] who are not nurses) has been defined in four ACNM documents: Definition of Midwifery and Scope of Practice of Certified Nurse-Midwives and Certified Midwives (ACNM, 2011a), the Core Competencies for Basic Midwifery Practice (ACNM, 2012a), Standards for the Practice of Midwifery (ACNM, 2011b), and the Code of Ethics (ACNM, 2013). The core competencies are organized into 16 hallmarks describing the art and science of midwifery and the components of midwifery care. The components of midwifery care include professional responsibilities, midwifery management processes, fundamentals, and care of women and of the newborn, within which are prescribed competencies. According to the definition, “CNMs are educated in two disciplines: nursing and midwifery” (ACNM, 2011a, p. 1). Competencies “describe the fundamental knowledge, skills and behaviors of a new practitioner” (ACNM, 2012a, p. 1). The hallmarks, components, and associated core competencies are the foundation on which midwifery curricula and practice guidelines are based. In addition to the competencies, there are eight ACNM standards that midwives are expected to meet (ACNM, 2011b) and a code of ethics (ACNM, 2013). The standards address issues such as qualifications, safety, patient rights, culturally competent care, assessment, documentation, and expansion of midwifery practice. Three ethical mandates related to the ACNM mission of midwifery to promote the health and well-being of women and newborns within their families and communities are identified in the ethics code. As of 2010, CNMs entering practice must earn a graduate degree, complete an accredited midwifery program, and pass a national certification examination (see Chapter 17 for detailed requirements; ACNM, 2011a); the type of graduate degree is not specified. The ACNM does recognize the value of doctoral education as a valid and valuable path for CNMs, as evidenced by a statement on the practice doctorate in midwifery, including competencies (ACNM, 2011c). Although not cited, these competencies align with those in the DNP Essentials (AACN, 2006); the ACNM recognizes that there are other paths for a practice doctorate in midwifery. At the present time, the ACNM (2015) does not support the DNP as a requirement for entry into nurse-midwifery practice. Reasons cited are: (1) midwifery practice is safe, based on the rigor of their curriculum standards and outcome data; (2) there is inadequate evidence to justify the DNP as a mandatory educational requirement for CNMs; and (3) the costs of attaining such a degree could limit the applicant pool and access to midwifery care (ACNM, 2012b). Midwifery organizations have recently addressed the aspects of the 2008 Consensus Model that they support and identified those aspects that are of concern (ACNM, Accreditation Commission for Midwifery Education, & American Midwifery Certification Board, 2011). International Organizations and Conceptualizations of Advanced Practice Nursing In this section, issues of a common language and conceptual framework for advanced practice nursing are addressed. International perspectives on advanced practice nursing are covered more extensively in Chapter 6. The ICN Nurse Practitioner/Advanced Practice Nursing Network (2016) defines a nurse practitioner/advanced practice nurse as “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice.” A master's degree is recommended for entry level (ICN Nurse Practitioner/Advanced Practice Nursing Network, 2016). Key concepts include educational preparation, the nature of practice, and regulatory mechanisms. The statement is necessarily broad, given the variations in health systems, regulatory mechanisms, and nursing education programs in individual countries. In 2008 the CNA published Advanced Nursing Practice: A National Framework, which defined advanced nursing practice, described educational preparation and regulation, identified the two APRN roles (CNS and NP), and specified competencies in clinical practice, research, and leadership. In addition, they have issued position statements on advanced nursing practice (CNA, 2007) that affirm the key points in the national framework document and define and describe the roles and contributions to health care of NPs (CNA, 2009b) and CNSs (CNA, 2009a). In 2010 the CNA published a Core Competency Framework for NPs, which included the incorporation of theories of advanced practice nursing. The CNA (2013) is also leading efforts not only to distinguish the role of the CNS from that of the NP, but to strengthen the role of the CNS, which includes ICN competencies. Furthermore, leaders have undertaken an evidence-based, patientcentered, coordinated effort (called a decision support synthesis) to develop, implement, and evaluate the advanced practice nursing roles of the CNS and NP in Canada (DiCenso et al., 2010), a process different from the one used to advance these roles in the United States. This process included a review of 468 published and unpublished articles and interviews conducted with 62 key informants and four focus groups that included a variety of stakeholders. The purpose of this work was to “describe the distinguishing characteristics of CNSs and NPs relevant to Canadian contexts”; identify barriers and facilitators to effective development and use of advanced practice nursing roles; and inform the development of evidence-based recommendations that individuals, organizations, and systems can use to improve the integration of advanced practice nurses into Canadian health care (DiCenso et al., 2010, p. 21). The European Specialist Nurses Organisations (2015) defined 10 core (generic) competencies of CNS practice in Europe. The competencies address clinical role, patient relationship, patient teaching/coaching, mentoring, research, organization and management, communication and teamwork, ethics and decision making, leadership/policymaking, and public health. The competencies were developed to clarify the role of the CNS and include advanced knowledge in anatomy, physiology, pathophysiology and pharmacology, similar to the APRN Consensus Model. It is expected that CNSs will collaborate with other health professionals to deliver high-quality patient care to ensure safety, quality of care, and equity of access to promote health and prevent disease. Section Summary: Implications for Advanced Practice Nursing Conceptualizations From this overview of organizational statements that clarify and advance APRN practice, it is clear that, nationally and internationally, stakeholders are actively defining advanced practice nursing. Progress in this area includes global agreement that this level of clinical nursing practice is advanced and builds on basic nursing education. As such, it requires additional education and is characterized by additional competencies and responsibilities. In the United States, the consensus on an approach to APRN regulation was critical for the following reasons: (1) clarifying what is an APRN and the role of graduate education and certification in licensing APRNs, (2) ensuring that APRNs are fully recognized and integrated in the delivery of health care, (3) reducing barriers to mobility of APRNs across state lines, (4) fostering and facilitating ongoing dialogue among APRN stakeholders, and (5) offering common language regarding regulation. Although there may not be unanimous agreement on the DNP as the requirement for entry into advanced practice nursing, the promulgation of the document fostered dialogue nationally and within APRN organizations on the clinical doctorate (whether or not it is the DNP) as a valid and likely path for APRNs to pursue. As a result, each APRN organization has taken a stand on the role of the clinical doctorate for those in the role and has developed or is developing doctoral-level clinical competencies. In doing so, it appears that the needs of their patients, members, other constituencies, and contexts have been considered. Until the time when a clinical doctorate becomes a requirement for entry into practice for all APRN roles, the development of doctoral-level competencies for APRN roles will help stakeholders distinguish between master's- and clinical doctorate–prepared APRNs with regard to competencies. Although important differences exist between roles and across countries, a common identity for APRNs resulting from policy and regulatory initiatives would facilitate communication within and outside the profession, consistent with assertions by Styles (1998) and Fawcett and Desanto-Madeya (2013) on the purposes of models. There are important differences among APRN organizations regarding such issues as doctoral preparation, which is also consistent with Fawcett and Desanto-Madeya's (2013) assertion that there is not one best model. The level of consensus regarding regulation in the United States reflects considerable and laudable progress, paving the way for policies and health care system transformations that will enable APRNs to be able to more fully ensure access to health care and improve its quality. The processes that have led to this juncture in the United States have required openness, civility, a willingness to disagree, and wisdom. Finally, there are at least two different approaches (collaborative policymaking in the United States and an evidence-based approach in Canada) to determine how best to assess contributions of APRNs and develop ways to integrate APRNs more fully into health care infrastructures in order to maximize their benefits to patients and populations. The global APRN community can examine these processes for insights on how to adapt them to suit their particular context. The organizational models described address professional roles, licensing, accreditation, certification, education, competencies, and clinical practice. The descriptive statements about APRN roles and competencies demonstrate the common elements that exist across all APRN roles. These include a central focus on and accountability for patient care, knowledge and skills specific to each APRN role, and a concern for patient rights. The published definitions, standards, and competencies offer models against which similarities and differences among APRN roles and practices can be distinguished, educational programs can be developed and evaluated, and knowledge and behaviors can be measured for certification purposes. These will also assist practitioners to understand, examine, and improve their own practice, and develop job descriptions. As advanced practice nursing moves forward in the United States and globally, the profession will continue to define situations in which a conceptual consensus, as well as alternative conceptualizations, will serve the public and the nursing profession. Conceptualizations of the Nature of Advanced Practice Nursing The APRN role-specific models promulgated by professional organizations raise several questions, such as: • What is common across APRN roles? • Can an overarching conceptualization of advanced practice nursing be articulated? • How can one distinguish among basic, expert, and advanced levels of nursing practice? Several authors have attempted to discern the nature of advanced practice nursing and address these questions. The extent to which all APRN roles are considered is not always clear; some only focus on CNS and NP roles. Select frameworks are presented here that address the nature of advanced practice nursing. From the present review of a number of frameworks, the concepts of roles, domain, and competency are among those most commonly used to explain advanced practice nursing. However, meanings are not consistent. Hamric's model, which uses the terms roles and competencies, is the only one that is integrative—that is, it explicitly considers all four APRN roles. Because it is integrative, has remained relatively stable since 1996, has informed the development of the DNP Essentials (AACN, 2006) and CNS competencies, and is widely cited, it is discussed first, enabling the reader to consider the extent to which important concepts are addressed by other models. Otherwise, the models are discussed in chronologic order and include examples from both US and international conceptual models of APRN practice. Hamric's Integrative Model of Advanced Practice Nursing One of the earliest efforts to synthesize a model of advanced practice that would apply to all APRN roles was developed by Hamric (1996). Hamric, whose early conceptual work was done on the CNS role (Hamric & Spross, 1983, 1989), proposed an integrative understanding of the core of advanced practice nursing, based on literature from all APRN specialties (Hamric, 1996, 2000, 2005, 2009, 2014; see Chapter 3). Hamric proposed a conceptual definition of advanced practice nursing and defining characteristics that included primary criteria (graduate education, certification in the specialty, and a focus on clinical practice with patients) and a set of core competencies (direct clinical practice, collaboration, guidance and coaching, evidence-based practice, ethical decision making, consultation, and leadership). This early model was further refined, together with Hanson and Spross in 2000 and 2005, based on dialogue among the editors. Key components of the model (Fig. 2.4) include the primary criteria for advanced nursing practice, seven advanced practice competencies with direct care as the core competency on which the other competencies depend, and environmental and contextual factors that must be managed for advanced practice nursing to flourish. FIG 2.4 Hamric's model of advanced practice nursing. The revisions to Hamric's original model highlight the dynamic nature of a conceptual model, and that essential features remain the same. Models are refined over time according to changes in practice, research, and theoretical understanding. The inherent stability and robustness of Hamric's model are noteworthy, particularly in light of the many potentially transformative advanced practice nursing initiatives being developed. This model forms the understanding of advanced practice nursing used throughout this text and has provided the structure for each edition of the book. Hamric's model has been used by contributors to this text to further elaborate specific competencies such as guidance and coaching (Spross, 2009; see Chapter 8), consultation (see Chapter 9), and ethical decision making (see Chapter 13). It has also informed the development of the DNP Essentials (AACN, 2006) and the revised CNS competencies and is widely cited in the advanced practice literature, which provides further evidence of its contribution to conceptualizing advanced practice nursing. In addition, integrative literature reviews provide further support for Hamric's integrative conceptualization of advanced practice nursing. Mantzoukas and Watkinson's (2007) literature review sought to identify “generic features” of advanced nursing practice; seven generic features were identified: (1) use of knowledge in practice, (2) critical thinking and analytic skills, (3) clinical judgment and decision making, (4) professional leadership and clinical inquiry, (5) coaching and mentoring, (6) research skills, and (7) changing practice. The first three generic features are consistent with the direct care competency in Hamric's model; these three characteristics seem directly related to clinical practice, which supports direct care as a central competency. The remaining four features are consistent with the three competencies of leadership, guidance and coaching, and evidencebased practice competency in Hamric's model. Similarly, an integrative literature review of CNS practice by Lewandowski and Adamle (2009) affirmed the direct care, collaboration, consultation, systems leadership, and coaching (patient and staff education) competencies in Hamric's model. Ten countries were represented in their review, and their findings were organized using NACNS's three spheres of influence. Within the first sphere, management of complex or vulnerable populations, they found three essential characteristics—expert direct care, coordination of care, and collaboration. In the sphere of educating and supporting interdisciplinary staff, substantive areas of CNS practice were education, consultation, and collaboration. Within the system sphere of influence, CNSs facilitate innovation and change. These findings lend support for the integration of Hamric's model with the NACNS model of CNS core competencies (NACNS/National CNS Competency Task Force, 2010). Conceptual Models of APRN Practice: United States Examples Fenton's and Brykczynski's Expert Practice Domains of the CNS and NP Some of the early work describing the practice domains of APRNs (CNSs and NPs) was conducted by Fenton (1985) and Brykczynski (1989), using Benner's model of expert nursing practice (Benner, 1984). To fully appreciate their contributions to the understanding of advanced practice, it is important to highlight some of Benner's key findings about nurses who are experts by experience. Although Benner's seminal work, From Novice to Expert (1984), has been used in the conceptualization of advanced practice nursing, it is important to note that Benner has not studied advanced practice nurses; her model was based on the expert practice of clinical nurses. Fenton's and Brykczynski's studies represent an extension of Benner's findings and theories to advanced practice nursing. The early work of Benner and associates informed the development of the first NONPF competencies, graduate curricula in schools of nursing, models of practice, and the standards for clinical promotion. A noted contribution of this early work was that it “put into words what they had always known about their clinical nursing expertise but had difficulty articulating” (Benner, Tanner, & Tesla, 2009). It is perhaps this impact that led to the sustained integration of Benner's studies of experts by experience into the APRN literature, including descriptions and development of competencies. Through the analysis of clinical exemplars discussed in interviews, Benner (1984) derived a range of competencies that resulted in the identification of seven domains of expert nursing practice. Within this lexicon, these domains are a combination of roles, functions, and competencies, although the three were not precisely differentiated. The seven domains are the helping role, administering and monitoring therapeutic interventions and regimens, effective management of rapidly changing situations, diagnostic and monitoring function, teaching and coaching function, monitoring and ensuring the quality of health care practices, and organizational and work role competencies. Fenton (1985) and Brykczynski (1989) each independently applied Benner's model of expert practice to APRNs, examining the practice of CNSs and NPs, respectively. Fenton and Brykczynski (1993) jointly compared their earlier research findings to identify similarities and differences between CNSs and NPs. They verified that nurses in advanced practice were indeed experts, as defined by Benner, showing they were experts by more than experience alone. They identified additional domains and competencies of APRNs (Fig. 2.5). Across the top of Fig. 2.5 are the seven domains identified by Benner and the additional domain found in CNS practice (Fenton, 1985), that of consultation provided by CNSs to other nurses (rectangular dotted box, top right). Under this box are two new CNS competencies (hexagonal boxes). The third (rounded) box is a new NP competency identified by Brykczynski in 1989. In this study of NPs, Brykczynski identified an eighth domain (the management of health and illness in ambulatory care settings) and recognized it as a qualitatively different expression from the first two domains identified by Benner. For NPs, the new competencies were a result of the integration of the diagnostic-monitoring and administering-monitoring domains. FIG 2.5 Fenton's (1985) and Brykczynski's (1989) expert practice domains of the CNS and NP. Mgmt, Management; pt, patient. (From Fenton, M. V., & Brykczynski, K. A. [1993]. Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. Journal of Professional Nursing, 9[6], 313–326.) The figure also reveals new CNS and NP competencies identified by Fenton and Brykczynski's work. New CNS competencies were identified under the organization and work role domain (e.g., providing support for nursing staff) and the helping role, in addition to the consulting domain and competencies. New NP competencies were noted in seven of the eight domains (e.g., detecting acute or chronic disease while attending to illness under the diagnosticadministering domains). By examining the extent to which APRNs demonstrate the seven domains found in experts by experience and uncovering differences, the findings offer insight into the differences between expert and advanced practice. In addition, Fenton and Brykczynski's work also described ways in which the CNS and NP roles may differ with regard to practice domains and competencies. These early findings suggest that a deeper understanding of advanced practice could be beneficial to understanding and conceptualizing advanced nursing practice. Benner's methods could be applied to studies of advanced practice nursing, with the following aims: (1) to confirm Fenton and Brykczynski's findings in CNS and NP roles and identify new domains and competencies across all four APRN roles, (2) to understand how APRN competencies develop in direct-entry graduate and RN graduate students, and (3) to compare the non–master's-prepared clinician's competencies with the APRN's competencies to distinguish components of expert versus advanced practice nursing. Studies focused on how APRNs acquire expertise in APRN and interprofessional competencies could inform future conceptualizations of advanced practice nursing. Calkin's Model of Advanced Nursing Practice Calkin's model (1984) was the first to explicitly distinguish the practice of experts by experience from advanced practice nursing of CNSs and NPs. Calkin developed the model to help nurse administrators differentiate advanced practice nursing from other levels of clinical practice in personnel policies. The model proposed that this could be accomplished by matching patient responses to health problems with the skill and knowledge levels of nursing personnel. In Calkin's model, three curves were overlaid on a normal distribution chart. Calkin depicted the skills and knowledge of novices, experts by experience, and APRNs in relation to knowledge required to care for patients whose responses to health care problems (i.e., health care needs) ranged from simple and common to complex and complicated (Fig. 2.6). A closer look at Fig. 2.6A, shows that patients have many more human responses (the highest and widest curve) than a beginning nurse would have the knowledge and skill to effectively manage. The impact of experience is illustrated in Fig. 2.6B. The highest and widest curve is effectively the same, but because of experience, expert nurses have more knowledge and skill. However, although the curves are higher and somewhat wider, the additional skill and knowledge of expert nurses do not yet match the range of responses they may encounter in the patients. In Fig. 2.6C, APRNs, by virtue of education and experience, do possess the knowledge and skills that enable them to respond to a wider range of human responses. The three curves in Fig. 2.6C are parallel each other, suggesting that even as less common human responses arise in clinical practice, APRNs are able to creatively and effectively respond to these unusual problems because of their advanced knowledge and skills. FIG 2.6 Calkin's model of advanced nursing practice. Patient responses correlated with the knowledge and skill of (A) beginning practitioners, (B) experienced nurses, and (C) advanced practice nurses (APNs). (From Calkin, J. D. [1984]. A model for advanced nursing practice. Journal of Professional Nursing, 14, 24–30.) Calkin used the framework to explain how APRNs perform under different sets of circumstances—when there is a high degree of unpredictability, new conditions, new patient population, or new sets of problems, and a wide variety of health problems requiring the services of “specialist generalists.” What APRNs do in terms of functions was also defined. For example, when patients' health problems elicit a wide range of human responses with continuing and substantial unpredictable elements, the APRN should do the following (Calkin, 1984): • Identify and develop interventions for the unusual by providing direct care. • Transmit this knowledge to nurses and, in some settings, to students. • Identify and communicate the need for research or carry out research related to human responses to these health problems. • Anticipate factors that may lead to unfamiliar human responses. • Provide anticipatory guidance to nurse administrators when the changes in the diagnosis and treatment of these responses may require altered levels or types of resources. A principal advantage of Calkin's model is that the skills, education, and knowledge needed by nurses are considered in relation to patient needs. It provides a framework for scholars to use in studying the function of APRNs in a variety of practice situations and should be a useful conceptualization for administrators who must maximize a multilevel interprofessional workforce and need to justify the use of APRNs. In today's practice environments, this conceptualization could be modified and applied in other settings based on whether a situation requires an APRN or RN and which mix of intra- and interprofessional staff and support staff is needed when settings have a high degree of predictability versus those that have high clinical uncertainty. The model has been left for others to test; although Calkin's thinking remains relevant, no new applications of the work were found. However, Brooten and Youngblut's work (2006) on the concept of “nurse dose,” based on years of empirical research, offers a similar understanding of the differences among beginners, experts by experience, and APRNs. They proposed, as did Calkin, that one needs to understand patients' needs and responses and the expertise, experience, and education of nurses to match nursing care to the needs of patients, but they did not cite Calkin's work. Similarly, the Synergy model in critical care is based, in part, on an understanding of patient and nurse characteristics consistent with Calkin's ideas (Curley, 1998). Strong Memorial Hospital's Model of Advanced Practice Nursing APRNs at Strong Memorial Hospital developed a model of advanced practice nursing (Ackerman, Clark, Reed, Van Horn, & Francati, 2000; Ackerman, Norsen, Martin, Wiedrich, & Kitzman, 1996; Mick & Ackerman, 2000). The model evolved from the delineation of the domains and competencies of the acute care NP (ACNP) role, conceptualized as a role that “combines the clinical skills of the NP with the systems acumen, educational commitment, and leadership ability of the CNS” (Ackerman et al., 1996, p. 69). The five domains are direct comprehensive patient care, support of systems, education, research, and publication and professional leadership. All domains have direct and indirect activities associated with them. In addition, three unifying threads influence each domain: collaboration, scholarship, and empowerment, which are illustrated as circular and continuous threads (Ackerman et al., 1996), (Fig. 2.7). These threads are operationalized in each practice domain. Ackerman et al. (2000) noted that the model is based on an understanding of the role development of APRNs; the concept of novice (APRN) to expert (APRN) is foundational to the Strong model (see later). FIG 2.7 The Strong Memorial Hospital's model of advanced practice nursing. (From Ackerman, M. H., Norsen, L., Martin, B., Wiedrich, J., & Kitzman H. J. [1996]. Development of a model of advanced practice. American Journal of Critical Care, 5, 68–73.) Direct comprehensive care includes a range of assessments and interventions performed by APRNs (e.g., history taking, physical assessment, requesting and/or performing diagnostic studies, performing invasive procedures, interpreting clinical and laboratory data, prescribing medications and other therapies, and case management of complex, critically ill patients). The support of systems domain includes indirect patient care activities that support the clinical enterprise and serve to improve the quality of care. These activities include consultation, participating in or leading strategic planning, quality improvement initiatives, establishing and evaluating standards of practice, precepting students, and promoting APRN practice. The education domain includes a variety of activities (e.g., evaluating educational programs, providing formal and informal education to staff, educating patients and families, and identifying and disseminating educational resources). The research domain addresses the use and conduct of research, while the publication and professional leadership domain includes APRN functions involved with disseminating knowledge about the ACNP role, participating in professional organizations, influencing health and public policy, and publishing. APRNs are expected to exert influence within and outside their institution. The unifying threads of collaboration, scholarship, and empowerment are attributes of advanced practice that exert influence across all five domains and characterize the professional model of nursing practice. Collaboration ensures that the contributions of all caregivers are valued. APRNs are expected to create and sustain a culture that supports scholarly inquiry, whether it is questioning a common nursing practice or developing and disseminating an innovation. APRNs support the empowerment of staff, ensuring that nurses have authority over nursing practice and opportunities to improve practice. The Strong model is a parsimonious model that has many similarities with other advanced practice conceptualizations. For example, its domains are consistent with the competencies delineated in Hamric's model. However, unlike Hamric's model, which posits direct care as the central competency that informs all other advanced nursing practice competencies, all domains of practice in the Strong model, including direct care, are considered “mutually exclusive of each other and exhaustive of practice behaviors” (Ackerman et al., 1996, p. 69). It is notable that this model was the result of a collaborative effort between practicing APRNs and APRN faculty members. One could infer that such a model would be useful for guiding clinical practice and planning curricula, two of the purposes of conceptual models outlined earlier in this chapter. The Strong model has informed studies of advanced practice nursing in critical care since its publication (e.g., Becker, Kaplow, Muenzen, & Hartigan, 2006; Chang, Gardner, Duffield, & Ramis, 2010; Mick & Ackerman, 2000). Further work by Gardner et al. (2013) in Australia used the Strong model to delineate the practice of APRNs (Grade 7) from the practice of registered nurse/midwife roles (Grade 5) and to delineate and define advanced practice nursing (Gardner et al., 2016). Ackerman, Mick, and Witzel (2010) have proposed an administrative model for managing APRNs and a central leadership model for hospital-based NPs (Bahouth et al., 2013). Texas Children's Hospital Transformational Advanced Professional Practice (TAPP) APRN Model The Strong Memorial Hospital model has also influenced the development of the Texas Children's Hospital transformational advanced professional practice (TAPP) APRN model (Elliott & Walden, 2015) (Fig. 2.8). To better reflect the current conceptualization of the APRN role, two additional domains of professional practice were added to the Strong model: quality and safety, and credentialing and regulatory practice. Professional ethics was also added as a unifying conceptual strand. FIG 2.8 Elliott and Walden's transformational advanced professional practice model. (From Elliott, E. D., & Walden, M. [2015]. Development of the transformational advanced professional practice model. Journal of the American Association of Nurse Practitioners, 27[9], 479–487.) The essence of the APRN role within this model is direct, comprehensive, family-centered care. The TAPP model includes this single patient care domain along with six professional development domains: organizational priorities; quality and safety; evidence-based practice and research; education; transformational professional practice; and credentialing and regulatory practice. The model recognizes that the amount of time and effort APRNs devote to the execution of the six professional development domains may vary dependent on needs of the system, patient population, and strengths and interest of individual APRNs. An added strength of the TAPP model is the description of APRN practice along three continuums: clinical expertise, health, and role. The clinical expertise continuum is reflective of the Benner (1984) model of expert practice (novice to expert), with expertise varying dependent on years of APRN and specialty experience and differing roles. The health continuum includes APRN care for patients who are healthy; for those who have common, stable or chronic health conditions; and for those who have complex, acute, critical, or rare health conditions. The role continuum of professional practice ranges from dependent on colleagues and mentors to assume a more independent role in each of the patient care and professional domains of practice. Although the authors indicate the model can be easily adapted to all four APRN roles, they also include physician assistants, thereby diluting the emphasis on models that conceptualize the unique practice of APRNs. In addition, because the NONPF core competencies (Thomas, Crabtree, Delaney, et al., 2011) were used along with the APRN Consensus Model (APRN Joint Dialogue Group, 2008) to develop the TAPP model, future work should test the appropriateness of this model for APRN roles in other than NP roles. Shuler's Model of NP Practice The historical importance of Shuler's model as an early NP model is briefly discussed here (Shuler & Davis, 1993a). Readers should refer to the original article to see the full model. Shuler's experience integrating nursing and medical knowledge skills into the NP role led to the development of a conceptual model that would illuminate the unique contributions and expanded role of NPs. Shuler's Nurse Practitioner Practice Model is a complex systems model that is holistic and wellness oriented. It is definitive and detailed in terms of how the NP-patient interaction, patient assessment, intervention, and evaluation should occur (Shuler & Davis, 1993a). Table 2.1 outlines key model constructs and related theories. Knowing that these familiar concepts are embedded in this comprehensive model may help readers appreciate its potential usefulness. TABLE 2.1 From Shuler, P. A., & Davis, J. E. (1993a). The Shuler nurse practitioner practice model: A theoretical framework for nurse practitioner clinicians, educators, and researchers, Part 1. Journal of the American Academy of Nurse Practitioners, 5, 11–18. Shuler's model is intended “to impact the NP domain at four levels: theoretical, clinical, educational, and research” (Shuler & Davis, 1993a). The model addresses important components of advanced practice nursing: (1) nursing's metaparadigm (person, health, nursing, and environment); (2) the nursing process; (3) assumptions about patients and NPs; and (4) theoretical concepts relevant to practice. The model could be characterized as a network or system of frameworks. Clinical application of Shuler's model is intended to describe the NP's expanded nursing knowledge and skills “into medicine,” the benefits for NP and patient, and a framework whereby NP services can be evaluated (Shuler & Davis, 1993b). Shuler and Davis (1993b) published a lengthy template for conducting a visit. Although it is difficult to imagine ready implementation into today's busy NP practices, Shuler and colleagues' clinical applications of the model have been published by Shuler (2000), Shuler and Davis (1993b), and Shuler, Huebscher, and Hallock (2001). In the current health care environment, the Circle of Caring model (Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011) may be more useful for addressing some of the issues that led Shuler to create her model—integrating nursing and skills traditionally associated with medicine while learning the NP role, and retaining a nursing focus while providing complex diagnostic and therapeutic interventions. Conceptual Models of APRN Practice: International Examples SickKids APRN Framework A conceptual model of APRN (CNS and NP) practice was developed in Canada for the care of children and adolescents (LeGrow, Hubley, & McAllister, 2010). The model was informed by four other models: the Strong Memorial Hospital model (King & Ackerman, 1995; Mick & Ackerman, 2000); the Illness Beliefs Model (Wright, Watson, & Bell, 1996); the Five Practices of Exemplary Leadership (Kouzes & Posner, 2002); and the CNA (2000) Advanced Nursing Practice National Framework, which includes APRN competencies. SickKids is a family-centered model that was designed to capture the essence of the pediatric APRN role in five domains: pediatric clinical practice, research and scholarly activities, interprofessional collaboration, education and mentorship, and organization and system management. It is applicable to various pediatric practice settings across the continuum of care from the community to the hospital. The model has been implemented throughout the organization. It has provided a common language for the conceptualization of the APRN role, to establish common expectations and competencies, establish professional development opportunities, and develop a competency-based performance evaluation. This is a promising model to conceptualize the APRN role. However, research is needed to assess the ability of the model to evaluate the impact and outcomes of pediatric APRN practice. Model of Exemplary Midwifery Practice In 2000, Kennedy introduced a model of exemplary midwifery practice to identify essential characteristics, specific outcomes, processes of care provided, and their relationship to specific health outcomes of women and/or infants (Fig. 2.9). The development of the model was informed by critical and feminist theories and a Delphi study using input from recipients of midwifery care and exemplary midwives, not all of whom were master's or doctorally prepared APRNs. FIG 2.9 Kennedy's abstract model of the dimensions of exemplary midwifery practice. (From Kennedy, H. P. [2000]. A model of exemplary midwifery practice: Results of a Delphi study. Journal of Midwifery & Women's Health, 45[1], 4–19.) The model is schematically presented as three concentric spheres. The inner sphere describes three dimensions of exemplary midwifery practice: therapeutics, caring, and the profession. Therapeutics illustrates how and why midwives choose and use specific therapies. Caring depicts how the midwife demonstrates care for and about the client, and the dimension of the profession examines how exemplary practice might be enhanced and accepted. The middle sphere of the model depicts five processes of exemplary midwifery practice: support for the normalcy of birth, vigilance and attention to detail, creation of a setting that is respectful and reflects the woman's needs, respect for the uniqueness of the woman and family, and updates on knowledge, personal and peer review and balance of professional personal life. Lastly, the outer sphere depicts five qualities of exemplary midwifery practice: (1) exceptional clinical skills and judgment, knowledge of self and limits, clinical objectivity, confidence, intelligence and intellectual curiosity; (2) commitment to empowering women, integrity and honesty, humility, realistic, gentle, warmth, nurturing and understanding and supportive; (3) commitment to the profession, accountability, motivation, love of the work of midwifery; (4) commitment to family-centered care, tolerance, nonjudgmental, compassion, interest in others, flexibility; and (5) belief in the normalcy of birth, commitment to the health of women and families, patience, maturity, wisdom, persistence, positive outlook, and calm. Although laudable efforts have been made to develop a conceptual model of exemplary midwifery practice, additional work is needed. For example, conceptual and operational definitions of the multiple concepts and the relationships among and between them need further clarification. In addition, because not all CNM participants in this study were educated and trained as APRNs, the model needs to be examined and tested in APRN-prepared CNMs to evaluate its utility and it ability to guide APRN CNM practice and improve outcomes for women and their families. Conceptual Framework of ACNP Role and Perceptions of Team Effectiveness A conceptual framework from Canada by Kilpatrick, LavoieTremblay, Lamothe, Ritchie, and Doran (2013) was developed using cross-case analysis to describe key concepts that affect ACNP role enactment, boundary work, and perceptions of team effectiveness (Fig. 2.10). The development of the conceptual framework was influenced by the conceptual framework of Sidani and Irvine (1999) for evaluating the NP role in the acute care setting and the Donabedian (1966, 2005) model of quality care that incorporates structures, processes, and outcomes. FIG 2.10 Kilpatrick et al.'s conceptual framework of ACNP role enactment, boundary work, and perceptions of team effectiveness. (From Kilpatrick, K., Lavoie-Tremblay, M., Lamothe, L., Ritchie, J. A., & Doran, D. [2013]. Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness. Journal of Advanced Nursing, 69[1], 205–217.) Presented as multiple concentric circles, this conceptual framework has three central process dimensions at its core: ACNP role enactment, boundary work, and perceptions of team effectiveness. There is a bidirectional relationship proposed between the central process dimensions. Key concepts are identified within each central process dimension and include medical and advanced practice nursing and role (ACNP role enactment process dimension); creating space, loss, trust, interpersonal dynamics, and time (Boundary Work process dimension); and decision making, communication, cohesion, care coordination, problem solving, and a focus on patient/family (Perceptions of Team Effectiveness process dimension). Although key concepts are identified, the conceptual and operational definitions of these concepts are not presented. Moving outward from the core of the conceptual framework are five concentric rings representing different layers of the structural dimensions (Patient, ACNP, Team, Organization, and Health care System) that affect the central process dimensions. The proximity of the layers is important: the closer the structural layer is to the core, the more the direct effect is on the central process dimensions. Dotted lines between the process and structural dimension represent the bidirectional relationship between the dimensions. Outcomes indicators include quality (timely care, patient follow-up, improved discharge planning); safety (safe patient discharges); cost; and team improved staff knowledge. Given the recent emphasis on teamwork and the enactment of highly functioning interprofessional teams to achieve improved patient outcomes, this framework is timely and novel because it focuses on the impact of ACNPs on teamwork. Future work should focus on the measurement of outcomes specific to and reflective of APRN care in light of the current scope of practice legislation, organizational support for the role, and patient and family perceptions of team effectiveness. Model for Maximizing NP Contributions to Primary Care Poghosyan, Boyd, and Clarke (2016) have proposed a conceptual model to optimize full scope of practice for NPs in primary care (Fig. 2.11). After completing a thorough review of the literature, the authors developed a comprehensive model describing potential factors that affect NP care and patient outcomes. Three factors were identified: scope of practice regulations, institutional policies, and practice environments. Scope of practice regulations is defined as regulations across the United States that vary from state to state (despite competency-based educational preparation and national certification examinations) that create barriers to NPs' abilities to practice to their full education and training, thereby creating barriers to optimal NP practice (e.g., hospital admitting privileges, recognition of primary care provider status, prescribing autonomy). Institutional policies are described as idiosyncratic differences between organizations even within the same state or jurisdiction that negatively impact an NP's ability to deliver patient care. These include restriction in NP practice beyond state legislation or regulation. Practice environments that support NP practice are defined as those that promote high-quality patient care and maximize the effectiveness and utility of primary care NPs. Positive practice environments promote favorable relationships between NPs and physicians and NPs and administration that support independent NP practice. Additionally, effective communication, similar vision and prioritization of care and teamwork support a favorable practice environment for primary care NPs. Lastly, negative issues that affect NP workforce outcomes include high workloads, complex patients, rapidly changing administrations, and organization structures. These negative issues can lead to job stress, job dissatisfaction, burnout, and turnover. FIG 2.11 Poghasyan, Boyd, and Clark's proposed model for maximizing contributions to primary care. (From Poghosyan, L., Boyd, D. R., & Clarke, S. P. [2016]. Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nursing Outlook, 64[2], 146–155.) The authors are commended on their work to develop a conceptual model to optimize full scope of practice for primary care NPs. As the authors noted, additional research is needed to fully understand the impact of restricted scope of practice and institutional policies on NP care and patient outcomes. Although the relationships between and among the variables will need to be tested, the model holds the potential to inform policy, practice, and patient outcomes. Section Summary: Implications for Advanced Practice Nursing Conceptualizations When one considers conceptualizations of advanced practice nursing described by professional organizations and individual authors, similarities and differences emerge. Many conceptual models address competencies that APRNs must possess. All are in agreement that the direct care of patients is central to APRN practice. Most models affirm two or more competencies identified by Hamric, and some models emphasize some competencies more than others. Some models (e.g., the Calkin and Strong models) address the issue of skill mix as it relates to APRNs, an issue of concern to administrators who hire APRNs. A notable difference across models is the extent to which the concept of environment as it relates to APRN practice is addressed. Another noted difference in the models is that only the Hamric model addresses all four APRN roles (CNS, CRNA, CNM and NP). In the next section, selected models that APRNs may find useful as they develop and evaluate their own practices are described. Models Useful for Advanced Practice Nurses in Their Practice Advanced Practice Nursing Transitional Care Models There are several models of transitional care in which care is provided by APRNs. Early work by Brooten et al. (1988) continues to inform these models of APRN care (e.g., Partiprajak, Hanucharurnkul, Piaseu, Brooten, & Nityasuddhi, 2011) and illustrates how a theory of clinical care can be studied to obtain a better understanding of the work of APRNs. It is a model that has evolved but has resulted in steady contributions to understanding and improving APRN practice. This theoretical and empirical steadfastness has had a significant influence on the new policies evolving as the United States undergoes health care reform. Using a conceptual model proposed by Doessel and Marshall (1985), Brooten et al. integrated this framework into their evaluation of outcomes of APRN transitional care with different clinical populations. APRN transitional care was defined as “comprehensive discharge planning designed for each patient group plus APN home follow-up through a period of normally expected recovery or stabilization” (Brooten et al., 2002, p. 370). Brooten's model was intended to address outlier patient populations (e.g., those whose care, for clinical reasons, was likely to cost more). Across all studies, care was provided by NPs and/or CNSs whose clinical expertise was matched to the needs of the patient population. In these studies, APRN care was associated with improved patient outcomes and reduced costs. Research by Brooten, Naylor, and others (Bradway et al., 2012) who have studied transitional care by APRNs has provided empirical support for several elements important to a conceptualization of advanced practice nursing. In a summary of the studies conducted, the investigators identified several factors that contribute to the effectiveness of APRNs: content expertise, interpersonal skills, knowledge of systems, ability to implement change, and ability to access resources (Brooten, Youngblut, Deatrick, Naylor, & York, 2003). This finding provides empirical support for the importance of the APRN competencies of direct care, collaboration, coaching, and systems leadership. Two other important findings were the existence of patterns of morbidity within patient populations and an apparent dose effect (i.e., outcomes seemed to be related to how much time was spent with patients, number of APRN interactions with patients, and numbers and types of APRN interventions; Brooten et al., 2003). Subsequently, based on this finding of a dose effect, Brooten and Youngblut (2006) proposed a conceptual explanation of “nurse dose.” Their explanation suggests that nurse dose depends on patient and nurse characteristics. For the nurse, differences in education and experience can influence the dose of nursing needed. The concept of nurse dose, which has empirical support, may enable the profession to differentiate more clearly among novice, expert, and advanced levels of nursing practice. Taken together, findings from this program of research suggest that characteristics of patients and characteristics and dose of APRN interventions are important to the conceptualization of advanced practice nursing. Finally, the fact that this program of research has used NPs and CNSs to intervene with patients provides support for a broad conceptual model of APRN practice that encompasses APRN characteristics, competencies, patient factors, environment, and other concepts that can inform role-specific models. Although there have been other studies of APRNs providing transitional care, Brooten's work is highlighted because of the additional analyses that were done and the ultimate influence on health policy of this program of research (e.g., Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). The findings help to understand the APRN characteristics and interventions that contributed to the success of the interventions and a model of care that evolved from the skilled care provided by APRNs. The impact of the research conducted by Naylor, Bowles, et al. (2011) using the Translational Care Model, in which APRNs are the primary coordinators of care, provide home visits, and collaborate with the patient, family caregivers, and health care colleagues (physicians, nurses, social workers, and other health team members), is evident in many of the provisions of the ACA and its implementation (Naylor, 2012). The Community-Based Care Transitions Program was created by Section 3026 of the ACA and is being implemented by the Centers for Medicare & Medicaid Services Partnership for Patients (2017). Dunphy and Winland-Brown's Circle of Caring: A Transformative, Collaborative Model A central premise of Dunphy and Winland-Brown's model (1998) is that the health care needs of individuals, families, and communities are not being met in a health care system dominated by medicine in which medical language (i.e., the International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM] codes) is the basis for reimbursement. They proposed the Circle of Caring to foster a more active and visible nursing presence in the health care system and to explain and promote medical-nursing collaboration. Dunphy and Winland-Brown's transformative model (Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011; Fig. 2.12) is a synthesized problem-solving approach to advanced practice nursing that builds on nursing and medical models (Dunphy & WinlandBrown, 1998). FIG 2.12 Dunphy and Winland-Brown's Circle of Caring model. NP, nurse practitioner. (From Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., Thomas, D. J., & Gallagher, L. M. [2011]. Primary care in the twenty-first century: A circle of caring. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter, & D. J. Thomas [Eds.]. Primary care: The art and science of advanced practice nursing [3rd ed., pp. 3–18]. Philadelphia: FA Davis.) The authors argued that a model such as theirs is needed because nursing and medicine have two different traditions, with the medical model being viewed as reductionistic and the nursing model being regarded as humanistic. Neither model, by itself, provided a structure that allowed APRNs to be recognized for their daily practice and the positive patient health outcomes that can be attributed to APRN care. The model's authors viewed the development of nursing diagnoses as an attempt to differentiate nursing care from medical care, but because few nursing diagnoses are recognized by current reimbursement systems, the nursing in APRN care was rendered invisible. The Circle of Caring model was proposed to incorporate the strengths of medicine and nursing in a transforming way. The conceptual elements are the processes of assessment, planning, intervention, and evaluation, with a feedback loop. Integrating a nursing model with a traditional medical model permits the following to occur: • The assessment and evaluation are contextualized, incorporating subjective and environmental elements into traditional history taking and physical examination. • The approach to therapeutics is broadened to include holistic approaches to healing and makes nursing care more visible. • Measured outcomes include patients' perceptions of health and care, not just physiologic outcomes and resource use. The assessment-planning-intervention-evaluation processes in linear configuration are encircled by caring. Caring is actualized through interpersonal interactions with patients and caregivers to which NPs bring patience, courage, advocacy, authentic presence, commitment, and knowing (Dunphy & Winland-Brown, 1998; Dunphy, Winland-Brown, Porter, Thomas, & Gallagher, 2011). Conceptual definitions of these terms would add to the understanding of how these processes interact with and affect the care provided by APRNs. The authors suggested that the model promotes the incorporation of the lived experience of the patient into the providerpatient interaction and that the process of caring is a prerequisite to APRNs providing effective and meaningful care to patients. The Circle of Caring is an integrated model of caregiving that incorporates the discrete strengths of nursing and medicine. This is an important concern for many graduate students because some may struggle with integrating their nursing expertise and philosophy with new knowledge and skills that were traditionally viewed as medicine. Although the authors regard the concept of caring as a way to bridge the gap between advanced practice nursing and medicine and raise awareness, the model provides no clear guidance on how faculty can help students to use the model to bridge this gap. Several issues remain to be considered. For example, if one goal of proposing the model is to resolve differences about the diagnostic language used by medicine and nursing to obtain reimbursement, no specific mechanism is offered for APRNs to resolve this issue using the model. The model does not seem to be described in enough detail to guide policymaking. The conceptual significance of encircling the four practice processes with the six caring processes is unclear, although the primary care textbook by Dunphy, Winland-Brown, Porter, and Thomas (2011) devotes a chapter to caring in the NP role (Boykin & Schoenhofer, 2011). Given today's health policy context, the value of this model, with its emphasis on the APRN-patient relationship and caring processes, could inform practice evaluation and research on APRN practices. For example, the Circle of Caring model has been used for the development of an online risk assessment of mental health (McKnight, 2011), evaluation of medication adherence (Palardy & March, 2011), and neonatal transport (Thomas, 2011). In addition, the primary care textbook (Dunphy, WinlandBrown, Porter, & Thomas, 2011) is informed by their Circle of Caring model. Given the emphasis on interprofessional education and efforts to distinguish advanced practice nursing from medical practice, empirical testing of this model is warranted. This testing would help determine whether the model has the following features: (1) is applicable to all APRN roles; (2) has the potential to be used to distinguish expert by experience practice from advanced practice; (3) is viewed by other disciplines as having an interprofessional focus that would promote collaboration; and (4) will result in more visibility for NPs and other APRNs in the health care system. Donabedian Structure/Process/Outcome Model Donabedian's structure/process/outcome model (2005) has been used as the conceptual model by several recent studies to evaluate the quality of APRN care (e.g., Bryant-Lukosius et al., 2016; Kilpatrick, Tchouaket, Carter, Bryant-Lukosius, & DiCenso, 2016; Kilpatrick et al., 2013). Originally designed to evaluate the quality of medical care, this model compasses three quality-of-care dimensions: structure, process, and outcomes. Structure is the care delivery context (e.g., hospitals, health care staff, cost, equipment) and the factors that dictate how health care providers and patients behave and are system measures of quality of care (Donabedian, 1980, 1986, 1988). Process involves the actions taken in the delivery of health care (e.g., diagnosis, treatment, education), whereas outcome is the effect of the health care on patients and populations. Outcome is often viewed as the key quality indicator of care delivery. Kilpatrick et al. used this model to describe the relationship between CNS role implementation, satisfaction, and intent to stay in the role (Kilpatrick et al., 2016) and to evaluate team effectiveness when an ACNP is added to the health care team (Kilpatrick et al., 2013). The model provided the framework to examine outcomes and barriers to CNS practice in Canada and the frequency with which components of the CNS role (clinical, education, research, leadership, scholarly and professional development, and consultation) were enacted. Findings indicate that CNS role components of clinical and research, along with balanced scholarly and professional development and consultation activities, were associated with role satisfaction. Additional research is needed to determine if implementation of the CNS role influences intention to remain in or actual departure from the role. Guided by the Donabedian model, Bryant-Lukosius et al. (2016) developed an evaluation framework to inform decisions about the effective utilization of APRNs in Switzerland (Fig. 2.13). An international group of stakeholders (e.g., APRNs, APRN educators, administrators, researchers) from Canada, Germany, Switzerland, and the United States convened to develop and refine the framework. The developed framework is deliberately broad and flexible to respond to the evolving APRN roles in Switzerland. Key concepts of the model are introduction stage, implementation, and long-term sustainability. The introduction stage includes the type of APRN and corresponding competencies. The implementation stage focuses on the resources (policies, education, funding) to support the different APRN roles and promote the optimal utilization and implementation of the role. Longterm sustainability focuses on long-term benefits and impact of APRN roles (consumers, system, providers) in Switzerland. Because the role of the APRN is in its early stage, the authors have indicated their plan to engage in concerted efforts with policymakers and other stakeholders to actively involve them in its use and application. Several resources have been developed to actualize this (e.g., toolkit, evaluation plan template). FIG 2.13 Bryant-Lukosius education framework matrix—key concepts for evaluating advanced practice nursing roles. (From Bryant-Lukosius, D., Spichiger, E., Martin, J., Stoll, H., Kellerhals, S. D., Fliedner, M., et al. [2016]. Framework for evaluating the impact of advanced practice nursing roles. Journal of Nursing Scholarship, 48[2], 201–209.) Recommendations and Future Directions Given the variety of conceptualizations and inconsistency in terminology, it is not surprising that APRN students and practicing APRNs would find the conceptualization of advanced practice nursing confusing. The challenge for APRNs (students and practicing nurses) is to find a model that works for them, that enables them to understand and evaluate their practices and attend to the profession's efforts to create a coherent, stable, and robust conceptualization of advanced practice nursing. Conceptualizations of Advanced Practice Nursing This overview of extant models of advanced practice nursing is necessarily cursory, primarily focused on western literature (Canada, Europe, United States). Although there is some agreement on selected elements of advanced practice, differences remain regarding the conceptualization of the ARPN. To promote a unified conceptualization of advanced practice nursing, the following recommendations are put forth: 1. Conduct a rigorous content analysis of the statements published by national and international professional organizations that describe the advanced practice nursing of recognized APRNs (CNMs, CNSs, CRNAs, certified NPs). This would be a natural evolution of the work done by the APRN Consensus Work Group, the NCSBN APRN Advisory Committee, the CNA, and others to inform future work. As part of this analysis, an assessment of the extent to which nursing's metaparadigmatic concepts are integrated into statements about the nature of advanced practice nursing should be undertaken. 2. Conduct a content analysis of statements that address advanced practice nursing promulgated by specialty organizations. 3. Review recent role delineation studies of the four APRN roles. 4. Conduct a comprehensive integrative review of the advanced practice literature, building on the work of Mantzoukas and Watkinson (2007) and Lewandowski and Adamle (2009). This could be modeled on the work of Reeves et al. (2011) and their conceptualization of interprofessional education, identifying concepts and relationships that need further development. 5. Synthesize results to collaboratively propose a definition of advanced practice nursing to be used nationally and globally. 6. Create a common structure for organizational statements about APRNs that ensures nursing concepts are included: a. Definition of nursing and advanced practice nursing b. Specification of assumptions c. Incorporation of the metaparadigmatic elements (persons, health and illness, nursing, environment) into scopes and introductions to key documents d. Referencing documents such as the ANA's social policy statement and the ICN's statements on nursing 7. Implement a structure for developing statements that define advanced practice nursing to explicate the foundational and philosophical underpinnings of each organization's approach to defining advanced practice nursing. 8. Use the results from recommendations 1 through 5 above to inform revisions of the DNP Essentials (AACN, 2006), standards, and other documents that address APRN LACE issues for APRN roles. Future revision of documents regarding APRNs should be informed by a clear conceptualization of advanced practice nursing and empirical evidence. 9. Because the terms advanced practice nursing and advanced nursing practice are being used to refer to APRN work in different ways in the United States versus internationally, revisit the work on definitions of these terms done by Styles (1998) and Styles and Lewis (2000) and clarify these definitions as they relate to APRNs. Consensus Building Around Advanced Practice Nursing A priority for the profession is a collaboratively developed conceptualization of advanced practice nursing and what is common across the various APRN roles. Achieving this is a prerequisite for building consensus among APRNs, stakeholder organizations, and policymakers and ensuring that all patients will benefit from advanced practice nursing. The APRN Consensus Model represents substantial progress in this area with regard to regulation. Studies are underway worldwide (see Chapter 6) that could inform efforts to refine conceptualizations of advanced nursing practice. Ongoing development of consensus on advanced practice nursing should involve: • Periodic updates on the progress of nationwide implementation of the regulatory model—successes and challenges (note that the NCSBN periodically updates state-by-state maps on its website). • Communication between national and global APRN accrediting and certification bodies. Because US nurse anesthetists and nurse-midwives operate under different accrediting and certification bodies and mechanisms than CNSs and NPs, their experience may be helpful in countries in which nurses and midwives are regulated separately, or where nurse anesthesia is not a practice role. • Consensus of common terms used in documents describing APRN practice. It is evident from this review that there is still a need for common language to describe advanced practice nursing. Clear articulation and consensus of the conceptual differences among terms such as essentials, competencies, hallmarks, and standard of care is needed among the various users within the profession and among other stakeholders. The responses of the AANA, ACNM, NACNS, and NONPF to the DNP initiative and concerns about selective implementation of the APRN Consensus Model are likely to influence the evolution of advanced practice nursing in the next decade. The extent to which we reach agreement within the profession will affect policy related to advanced practice and whether the public recognizes and requests the services of APRNs. Disagreement on the nature and credentialing of advanced practice nursing should be resolved by continued efforts to foster true consensus by: • Addressing the legitimate concerns of these organizations (e.g., impact on access to care, concerns about certification or grandfathering existing APRNs) • Establishing priorities for negotiation and resolution by stakeholder groups and initiating a process to find common ground and address disagreements • In the face of disagreements, working toward agreement on a common identity to facilitate public understanding of APRN roles These consensus-building efforts are needed if our profession is to remain attractive to new nurses and new APRNs and to make room for evolving APRN roles. Consensus on Key Elements of Practice Doctorate Curricula Several authors have expressed concern that, because the DNP is a practice degree and not a research degree, it may not be demanding enough with regard to theory and research methods, which may be just as important for evaluating practice and testing practice models as they are in nursing Ph.D. programs. Although the ACNM does not currently support the practice doctorate for entry into practice and the AANA has delayed endorsing doctoral preparation for entry into practice until 2025 and the NACNS until 2030, APRN organizations have prepared doctoral-level competencies that are consistent with those proposed in the DNP. One question that will need to be addressed is whether regulations will specify which type of nursing practice doctorate will be needed when, and if, a doctorate becomes the entry-level credential for all APRNs because, as Dreher (2011) has noted, there are other practice doctorates in nursing. Research on Advanced Practice Nurses and Their Contribution to Patients, Teams, and System Outcomes Theory-based research on APRNs' contributions to improved patient outcomes and cost-effectiveness is needed to inform and validate the conceptualizations of advanced practice nursing. Increased knowledge about advanced practice nursing is critical (see Chapter 23). The worth of any service depends on the extent to which practice meets the needs and priorities of health care systems, the public policy arena, and society in general. In addition to research that links advanced practice nursing with outcomes, the following recommendations are put forth: 1. Promising conceptual models of advanced practice nursing should be refined based on research that validates key concepts and tests theoretical propositions associated with these models. 2. Studies are needed to examine advanced practice nursing across APRN roles and between physician and APRN practices with regard to processes and outcomes. Studies conducted across APRN roles can determine whether the assumption that a core set of competencies is used by all APRNs is valid, and the activities that differentiate one APRN role from another. The studies of APRN and physician practice can identify the factors that distinguish APRN practice from physician practice as a basis for understanding differences in outcomes and developing proposals to optimally use each provider to achieve high-quality, patient-centered, costeffective care. 3. As conceptualizations of interprofessional teams evolve, the roles and contributions of APRNs and their interdisciplinary colleagues to outcomes need examination. When there is a better empirical understanding of the similarities and differences across APRN roles and between physicians and APRNs, this knowledge must be packaged and presented to colleagues in other disciplines, policymakers, and the public. These data will be key to educating physician colleagues, health care consumers, and policymakers about the meaning and relevance of advanced practice nursing to the health of our society. Conclusion Consensus regarding a conceptual model of advanced practice nursing is needed to guide practice, research, and public policy. The future of advanced practice nursing depends on the extent to which practice meets the needs and priorities of society, health care systems, and the public policy arena. A stable, robust model of advanced practice nursing will serve to guide the development of advanced practice nursing and ensure that patients will have access to APRN care. Issues, limitations, and imperatives related to conceptualizing advanced practice nursing have been identified in this review of conceptual models of APRN practice. The nursing profession, nationally and internationally, remains at a critical juncture with regard to advanced practice nursing. In each country in which APRNs practice, the need to move forward with a unified voice on this issue is urgent if APRNs and the nursing profession as a whole are to fulfill their social contract with the individuals, institutions, and communities. A unified conceptualization of advanced practice nursing focuses the efforts of the profession on preparing APRNs, promulgating policies, and fostering research to enable the realization of the outcomes, including maximizing the social contribution of APRNs to the health needs of society and promoting the actualization of APRNs. 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Moving from individual roles to functional teams: A semester-long course in case-based decision making. Journal of Interprofessional Care. 2017;7:11–16. Thomas J. The Circle of Caring Model for neonatal transport. Neonatal Network. 2011;30(1):14–20. Thomas AC, Crabtree MK, Delaney KR, Dumas MA, Kleinpell R, Logsdon MC, et al. National Organization of Nurse Practitioners Faculties. [Retrieved from] http://www.nonpf.org/? page=14&hhSearchTerms=%22April+and+2011%22; 2011. Thoun DS. Specialty and advanced practice nursing: Discerning the differences. Nursing Science Quarterly. 2011;24:216–222. Validation Panel of the National Association of Clinical Nurse Specialists. Criteria for the evaluation of clinical nurse specialist, master's, practice doctorate, and post-graduate certificate educational programs. [Retrieved from] http://www.nacns.org/docs/CNSEducationCriteria.pdf; 2011. Wong FKY, Peng G, Kan EC, Li Y, Lau A, Zhang L, et al. Description and evaluation of an initiative to develop advanced practice nurses in mainland China. Nurse Education Today. 2010;30(4):344–349. Wright LM, Watson WL, Bell JM. Beliefs: The heart of healing in families and illness. Basic Books: New York; 1996. Zimmer P, Brykczynski K, Martin A, Newberry Y, Price M, Warren B. National guidelines for nurse practitioner education. National Organization of Nurse Practitioner Faculties: Seattle; 1990. CHAPTER 3 A Definition of Advanced Practice Nursing Ann B. Hamric, Mary Fran Tracy “Nothing is more powerful than an idea whose time has come” —Victor Hugo CHAPTER CONTENTS Distinguishing Between Specialization and Advanced Practice Nursing, 62 Distinguishing Between Advanced Nursing Practice and Advanced Practice Nursing, 63 Defining Advanced Practice Nursing, 64 Core Definition of Advanced Practice Nursing, 65 Conceptual Definition, 65 Primary Criteria, 66 Seven Core Competencies of Advanced Practice Nursing, 69 Direct Clinical Practice: The Central Competency, 69 Additional Advanced Practice Nurse Core Competencies, 70 Scope of Practice, 72 Differentiating Advanced Practice Roles: Operational Definitions of Advanced Practice Nursing, 72 Workforce Data, 72 Four Established Advanced Practice Nurse Roles, 73 Critical Elements in Managing Advanced Practice Nursing Environments, 74 Implications of the Definition of Advanced Practice Nursing, 76 Implications for Advanced Practice Nursing Education, 76 Implications for Regulation and Credentialing, 76 Implications for Research, 77 Implications for Practice Environments, 78 Conclusion, 79 Key Summary Points, 79 This chapter considers two central questions that provide the foundation for this text: • Why is it important to define carefully and clearly what is meant by the term advanced practice nursing? • What distinguishes the practices of advanced practice registered nurses (APRNs) from those of other nurses and other health care providers? Advanced practice nursing is considered here as a concept, not a role, a set of skills, or a substitution for physicians. Rather, it is a powerful idea, the origins of which date back more than a century. Such a conceptual definition provides a stable core understanding for all APRN roles (see Chapter 2), it promotes consistency in practice that can aid others in understanding what this level of nursing entails, and it promotes the achievement of value-added patient outcomes and improvement in health care delivery processes. Advanced practice nursing is a relatively new concept in nursing's evolution (see Chapter 1). Although debates and dissension are necessary and even healthy in forging consensus, ultimately the profession must agree on the key issues of definition, education, credentialing, and practice. Such agreement is critically important to the survival, much less the growth, of advanced practice nursing. In the international context, although these issues may be defined differently by different countries, in-country standardization is likewise essential. In this chapter, advanced practice nursing is defined and the scope of practice of APRNs is discussed. Various APRN roles are differentiated and key factors influencing advanced practice in health care environments are identified. The importance of a common and unified understanding of the distinguishing characteristics of advanced practice nursing is emphasized. The advanced practice of nursing builds on the foundation and core values of the nursing discipline. APRN roles do not stand apart from nursing; they do not represent a separate profession, although references to “the nurse practitioner (NP) profession,” for example, are seen in the literature. It is the nursing core that contributes to the distinctiveness seen in APRN practices as compared to non-nursing providers such as physician assistants. According to the American Nurses Association (ANA, 2010), nursing practice has seven essential features: … provision of a caring relationship that facilitates health and healing; attention to the range of human experiences and responses to health and illness within the physical and social environments; integration of assessment data with knowledge gained from an appreciation of the patient or the group; application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking; advancement of professional nursing knowledge through scholarly inquiry; influence on social and public policy to promote social justice; and, assurance of safe, quality, and evidencebased practice. (p. 9) These characteristics are equally essential for advanced practice nursing. Core values that guide nurses in practice include advocating for patients; respecting patient and family values and informed choices; viewing individuals holistically within their environments, communities, and cultural traditions; and maintaining a focus on disease prevention, health restoration, and health promotion (ANA, 2015a; Friberg & Creasia, 2011; Hood, 2014). These core professional values also inform the central perspective of advanced practice nursing. Efforts to standardize the definition of advanced practice nursing have been ongoing since the 1990s (American Association of Colleges of Nursing [AACN], 1995, 2006; ANA, 1995, 2003, 2010; Hamric, 1996, 2000, 2005, 2009, 2014; National Council of State Boards of Nursing [NCSBN], 1993, 2002, 2008). However, full clarity regarding advanced practice nursing has not yet been achieved, even as this level of nursing practice spreads around the globe. The growing international use of APRNs with differing understandings in various countries has only complicated the picture (see Chapter 6). Different interpretations of advanced practice (AACN, 2006; ANA, 2013), debates about who is and is not an APRN, and discrepancies in educational preparation for APRNs remain issues for the international community, even as efforts are underway by the International Council of Nurses to develop a standardized definition of advanced practice nursing (A. Scanlon, personal communication, December 2016). In spite of this lack of clarity (Dowling, Beauchesne, Farrelly, & Murphy, 2013; Pearson, 2011; Ruel & Motyka, 2009), emerging consensus on key features of the concept is increasingly evident. The definition developed by Hamric has been relatively stable throughout the six editions of this book. The primary criteria used in this definition are now standard elements used in the United States and, increasingly, elsewhere to regulate APRNs. Similarly, consensus is growing in understanding advanced practice nursing in terms of core competencies. Even authors who deny a clear understanding of the concept propose competencies—variously called attributes, components, or domains—that are generally consistent with, although not always as complete as, the competencies proposed here. It is important to distinguish the conceptual definition of advanced practice nursing from regulatory requirements for any APRN role (NCSBN, 2008). Of necessity, regulatory understandings focus on the more basic and measurable primary criteria of graduate educational preparation, advanced certification in a particular population focus, and practice in one of the four common APRN roles: nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM). This approach is clearly seen in the APRN definition outlined in the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008) and has been very helpful and influential in standardizing state requirements for APRN licensure across the United States. Although necessary for regulation, however, this approach does not constitute an adequate understanding of advanced practice nursing. Limiting the profession's understanding of advanced practice nursing to regulatory definitions can lead to a reductionist approach that results in a focus on a set of concrete skills and activities, such as diagnostic acumen or prescriptive authority. Understanding the advanced practice of the nursing discipline requires a definition that encompasses broad areas of skilled performance (the competency approach). As Chapter 2 notes, conceptual models and definitions are also useful for providing a robust framework for graduate APRN curricula and for building an APRN professional role identity. Distinguishing Between Specialization and Advanced Practice Nursing Before the definition of advanced practice nursing can be explored, it is important to distinguish between specialization in nursing and advanced practice nursing. Specialization involves the development of expanded knowledge and skills in a selected area within the discipline of nursing. All nurses with extensive experience in a particular area of practice (e.g., pediatric nursing, trauma nursing) are specialized in this sense. As the profession has advanced and responded to changes in health care, specialization and the need for specialty knowledge have increased. Thus few nurses are generalists in the true sense of the word (Kitzman, 1989). Although family NPs traditionally represented themselves as generalists, they are specialists in the sense discussed here because they have specialized in one of the many facets of health care—namely, primary care. As noted in Chapter 1, early specialization involved primarily on-the-job training or hospital-based training courses, and many nurses continue to develop specialty skills through practice experience and continuing education. Examples of currently evolving specialties include genetics nursing, forensic nursing, and clinical transplant coordination. As specialties mature, they may develop graduate-level clinical preparation and incorporate the competencies of advanced practice nursing for their most advanced practitioners (Hanson & Hamric, 2003; also see Chapter 5); examples include critical care, oncology nursing, and palliative care nursing. The nursing profession has responded in various ways to the increasing need for specialization in nursing practice. The creation of specialty organizations, such as the American Association of CriticalCare Nurses and the Oncology Nursing Society, has been one response. The creation of APRN roles—the CRNA and CNM roles early in nursing's evolution and the CNS and NP roles more recently —has been another response. A third response has been the development of specialized faculty, nursing researchers, and nursing administrators. Nurses in all these roles can be considered specialists in an area of nursing (e.g., education, research, administration); some of these roles may involve advanced education in a clinical specialty as well. However, they are not necessarily advanced practice nursing roles. Advanced practice nursing includes specialization but also involves expansion and educational advancement (ANA, 1995, 2003, 2015b; Cronenwett, 1995). As compared with basic nursing practice, APRN practice is further characterized by the following: (1) acquisition of new practice knowledge and skills, particularly theoretical and evidence-based knowledge, some of which overlaps the traditional boundaries of medicine; (2) significant role autonomy; (3) responsibility for health promotion in addition to the diagnosis and management of patient problems, including prescribing pharmacologic and nonpharmacologic interventions; (4) the greater complexity of clinical decision making and leadership in organizations and environments; and (5) specialization at the level of a particular APRN role and population focus (ANA, 1996, 2015b; NCSBN, 2008). It is necessary to distinguish between specialization as understood in this chapter and the term population focus. The framers of the Consensus Model for APRN regulation were interested in licensing and regulating advanced practice nursing in two broad categories. The first was regulation at the level of role—CNS, NP, CRNA, or CNM. The second category was termed population focus and, although not explicitly defined, six population foci were identified: family and individual across the life span, adult-gerontology, pediatrics, neonatal, women's health and gender-related, and psychologic and mental health. These foci are at different levels of specialization; for example, family and individual across the life span is broad, whereas neonatal is a subspecialty designation under the specialty of pediatrics. Therefore population focus is not synonymous with specialization and should not be understood in the same light. As the Consensus Model states: Education, certification, and licensure of an individual must be congruent in terms of role and population foci. APRNs may specialize but they cannot be licensed solely within a specialty area. In addition, specialties can provide depth in one's practice within the established population foci. … Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations. (APRN Joint Dialogue Group, 2008, p. 6) Distinguishing Between Advanced Nursing Practice and Advanced Practice Nursing The terms advanced practice nursing and advanced nursing practice have distinct definitions and cannot be seen as interchangeable. In particular, recent definitions of advanced nursing practice do not clarify the clinically focused nature of advanced practice nursing. For example, the third edition of Nursing's Social Policy Statement defines the term advanced nursing practice as “characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education” (ANA, 2010, p. 9). This broad definition has evolved from the AACN's Position Statement on the Practice Doctorate in Nursing (AACN, 2004), which recommended doctoral-level educational preparation for individuals at the most advanced level of nursing practice. The Doctor of Nursing Practice (DNP) position statement (AACN, 2004) advanced a broad definition of advanced nursing practice as the following: … any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy (p. 3). A definition this broad goes beyond advanced practice nursing to include other advanced specialties not involved in providing direct clinical care to patients, such as administration, policy, informatics, and public health. One reason for such a broad definition was the desire to have the DNP degree be available to nurses practicing at the highest level in many varied specialties, not only those in APRN roles. A decision was reached by the original task force (AACN, 2004) that the DNP degree was not to be a clinical doctorate, as was advocated in early discussions (Mundinger et al., 2000) but, rather, a practice doctorate in an expansive understanding of the term practice. The AACN's The Essentials of Doctoral Education for Advanced Nursing Practice (2006) distinguishes between roles with an aggregate, systems, and organizational focus (characterized as “advanced specialties”) and roles with a direct clinical practice focus (APRN roles of CNS, NP, CRNA, and CNM), while recognizing that these two groups share some essential competencies. It is important to understand that the DNP is a degree, much as is the Master's of Science in Nursing (MSN), and not a role; DNP graduates can assume varied roles, depending on the specialty focus of their program. Some of these roles are not APRN roles as advanced practice nursing is defined here. Although the AACN has made attempts to be clear about the terms advanced nursing practice and advanced practice nursing in their statements on DNP education, this is a difficult distinction to understand. The nuances in the differences between these terms have not been clear to nurses in education and practice, professionals outside of nursing, and, at times, even DNP graduates themselves. As a result, the specific distinctions between the advanced specialties (such as administration) and APRN roles continue to require clarification. The current confusion in the United States also has global implications because the international community prefers advanced nursing practice when referring to direct care roles that are comparable to US APRN roles (Staser, Cashin, Buckley, & Donoghue, 2014). Advanced practice nursing is a concept that applies to nurses who provide direct patient care to individual patients and families. As a consequence, APRN roles involve expanded clinical skills and abilities and require a different level of regulation than non-APRN roles. These skills afford APRNs unique perspectives in making broader practice decisions for individuals and populations specifically in their specialty areas. This text focuses on advanced practice nursing and the varied roles of APRNs. Graduate programs that prepare students for APRN roles will have different curricula from those preparing students for administration, informatics, or other specialties that do not have a direct practice component (AACN, 2006). Defining Advanced Practice Nursing As noted, the concept of advanced practice nursing continues to be defined in various ways in the nursing literature. The CINAHL Database (2016) defines advanced practice broadly as anything beyond the staff nurse role: “The performance of additional acts by registered nurses who have gained added knowledge and skills through post-basic education and clinical experience.” As noted with the DNP definition, a definition this broad incorporates many specialized nursing roles, not all of which should be considered as advanced practice nursing. Advanced practice nursing is often defined as a constellation of four roles: the NP, CNS, CNM, and CRNA (NCSBN, 2002, 2008; Stanley, 2011). For example, the third edition of Nursing: Scope and Standards of Practice does not provide a definition of advanced practice nursing but uses a regulatory and role-based definition of APRNs: A nurse who has completed an accredited graduate-level education program preparing her or him for the role of certified nurse practitioner, certified registered nurse anesthetist, certified nursemidwife, or clinical nurse specialist; has passed a national certification examination that measures the APRN-, role-, and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN. (ANA, 2015b, p. 2–3) In the past, some authors discussed advanced practice nursing only in terms of selected roles such as the NP and CNS roles (Lindeke, Canedy, & Kay, 1997; Rasch & Frauman, 1996) or the NP role exclusively (Hickey, Ouimette, & Venegoni, 2000; Mundinger, 1994). Defining advanced practice nursing in terms of particular roles limits the concept and denies the unfortunate reality that some nurses in the four APRN roles are not using the core competencies of advanced practice nursing in their practice. These definitions are also limiting because they do not incorporate evolving APRN roles. Thus although such role-based definitions are useful for regulatory purposes, it is preferable to define and clarify advanced practice nursing as a concept without reference to particular roles. Core Definition of Advanced Practice Nursing The definition proposed in this chapter builds on and extends the understanding of advanced practice nursing proposed in the first five editions of this text. Important assertions of this discussion are as follows: • Advanced practice nursing is a function of educational and practice preparation and a constellation of primary criteria and core competencies. • Direct clinical practice is the central competency of any APRN role and informs all the other competencies. • All APRNs share the same core criteria and competencies, although the actual clinical skill set varies depending on the needs of the APRN's specialty patient population. A definition should also clarify the critical point that advanced practice nursing involves advanced nursing knowledge and skills; it is not a medical practice, although APRNs perform expanded medical therapeutics in many roles. Throughout nursing's history, nurses have assumed medical roles. For example, common nursing tasks such as blood pressure measurement and administration of chemotherapeutic agents were once performed exclusively by physicians. When APRNs begin to transfer new skills or interventions into their repertoire, these become nursing skills, informed by the clinical practice values of the profession. Actual practices differ significantly based on the particular role adopted, the specialty practiced, and the organizational framework within which the role is performed. In spite of the need to keep job descriptions and job titles distinct in practice settings, it is critical that the public's acceptance of advanced practice nursing be enhanced and confusion decreased. As Safriet (1993, 1998) noted, nursing's future depends on reaching consensus on titles and consistent preparation for title holders. The nursing profession must be clear, concrete, and consistent about APRN titles and their functions in discussions with nursing's larger constituencies: consumers, other health care professionals, health care administrators, and health care policymakers. Conceptual Definition Advanced practice nursing is the patient-focused application of an expanded range of competencies to improve health outcomes for patients and populations in a specialized clinical area of the larger discipline of nursing.a In this definition, the term competencies refers to a broad area of skillful performance; seven core competencies combine to distinguish nursing practice at this level. Competencies include activities undertaken as part of delivering advanced nursing care directly to patients. Some competencies are processes that APRNs use in all dimensions of their practice, such as collaboration and leadership. At this stage of the development of the nursing discipline, competencies may be based in theory, practice, or research. Although the discipline is expanding its research-based evidence to guide practice, an expanded ability to use theory also is a key distinguishing feature of advanced practice nursing. In addition, a strong experiential component is necessary to develop the competencies and clinical practice expertise that characterize APRN practice. Graduate education and in-depth clinical practice experiences work together to develop the APRN. The definition also emphasizes the patient-focused and specialized nature of advanced practice nursing. APRNs expand their capability to provide and direct care, with the ultimate goal of improving patient and specialty population outcomes; this focus on outcome attainment is a central feature of advanced practice nursing and the main justification for differentiating this level of practice. Finally, the critical importance of ensuring that any type of advanced practice is grounded within the larger discipline of nursing is made explicit. Certain activities of APRN practice overlap with those performed by physicians and other health care professionals. However, the experiential, theoretical, and philosophical perspectives of nursing make these activities advanced nursing when they are carried out by an APRN. Advanced practice nursing further involves highly developed nursing skill in areas such as guidance and coaching, as well as the performance of select medical interventions. Particularly with regard to physician practice, the nursing profession needs to be clear that advanced practice nursing is embedded in the nursing discipline—the advanced practice of nursing is not the junior practice of medicine. Advanced practice nursing is further defined by a conceptual model integrating three primary criteria and seven core competencies, one of them central to the others. This discussion and the chapters in Part II of this text isolate each of these core competencies to clarify them. The reader should recognize that this is only a heuristic device for clarifying this conceptualization of advanced practice nursing. In reality, these elements are integrated into an APRN's practice; they are not separate and distinct features. The concentric circles in Figs. 3.1 through 3.3 represent the seamless nature of this interweaving of elements. In addition, an APRN's skills function synergistically to produce a whole that is greater than the sum of its parts. The essence of advanced practice nursing is found not only in the primary criteria and competencies demonstrated, but also in the synthesis of these elements into a unified composite practice that conforms to the conceptual definition just presented. FIG 3.1 Primary criteria of advanced practice nursing. Primary Criteria Certain criteria (or qualifications) must be met before a nurse can be considered an APRN. Although these baseline criteria are not sufficient in and of themselves, they are necessary core elements of advanced practice nursing. The three primary criteria for advanced practice nursing are shown in Fig. 3.1 and include an earned graduate degree with a concentration in an advanced practice nursing role and population focus, national certification at an advanced level, and a practice focused on patients and their families. As noted, these criteria are most often the ones used by states to regulate APRN practice because they are objective and easily measured (see Chapter 22). Graduate Education First, the APRN must possess an earned graduate degree with a concentration in an APRN role. This graduate degree may be a master's or a DNP. Advanced practice students acquire specialized knowledge and skills through study and supervised practice at the graduate level. Curricular content includes theories and research findings relevant to the core of a particular advanced nursing role, population focus, and relevant specialty. For example, a CNS interested in palliative care will need coursework in CNS role competencies, the adult population focus, and the palliative care specialty. Because APRNs assess, manage, and evaluate patients at the most independent level of clinical nursing practice, all APRN curricula contain specific courses in advanced health and physical assessment, advanced pathophysiology, and advanced pharmacology (the so-called “three Ps”; AACN, 1995, 2006, 2011). Expansion of practice skills is acquired through faculty-supervised clinical experience, with master's programs requiring a minimum of 500 clinical hours and DNP programs requiring 1000 hours. As noted earlier in the ANA definition, there is consensus that a master's education in nursing is a baseline requirement for advanced practice nursing; nurse-midwifery was the latest APRN specialty to agree to this requirement (American College of Nurse-Midwives [ACNM], 2009). Why is graduate educational preparation necessary for advanced practice nursing? Graduate education is a more efficient and standardized way to inculcate the complex competencies of APRNlevel practice than nursing's traditional on-the-job or apprentice training programs (see Chapter 5). As the knowledge base within specialties has grown, so too has the need for formal education at the graduate level. In particular, the skills necessary for evidence-based practice and the theory base required for advanced practice nursing mandate education at the graduate level. Some of the differences between basic and advanced practice in nursing are apparent in the following: the range and depth of APRNs' clinical knowledge; APRNs' ability to anticipate patient responses to health, illness, and nursing interventions; their ability to analyze clinical situations and explain why a phenomenon has occurred or why a particular intervention has been chosen; the reflective nature of their practice; their skill in assessing and addressing nonclinical variables that influence patient care; and their attention to the consequences of care and improving patient outcomes. Because of the interaction and integration of graduate education in nursing and extensive clinical experience, APRNs are able to exercise a level of discrimination in clinical judgment that is unavailable to other experienced nurses (Spross & Baggerly, 1989). Professionally, requiring at least master's-level preparation is important to create parity among APRN roles so that all can move forward together in addressing policymaking and regulatory issues. This parity advances the profession's standards and ensures more uniform credentialing mechanisms. Moving toward a doctoral-level educational expectation may also enhance nursing's image and credibility with other disciplines. Decisions by other health care providers, such as pharmacists, physical therapists, and occupational therapists, to require doctoral preparation for entry into their professions provided compelling support for nursing to establish the practice doctorate for APRNs to achieve parity with these disciplines (AACN, 2006). Nursing has a particular need to achieve greater credibility with medicine. Organized medicine has historically been eager to point to nursing's internal differences in APRN education as evidence that APRNs are inferior providers. The clinical nurse leader (CNL) role represents a new and different understanding of the master's credential. Historically, master's education in nursing was, by definition, specialized education (see Chapter 1). However, the master's-prepared CNL is described as an “advanced generalist”, a staff nurse with expanded leadership skills at the point of care (AACN, 2007). The AACN's revision of The Essentials of Master's Education in Nursing (2011) was developed for this generalist practice, whereas the DNP Essentials (AACN, 2006) are aligned more with the understanding of advanced practice nursing described here. Even though CNLs have expanded leadership skills and graduate-level education, they are clearly not APRNs. APRN graduate education is highly specialized and involves preparation for an expanded scope of practice, neither of which characterizes CNL education. The existence of generalist and APRN specialty master's programs has the potential to confuse consumers, institutions, and nurses alike; it is incumbent on educational programs to clearly differentiate the curricula for generalist CNL versus specialist APRN roles to avoid role confusion for these graduates. It is likewise important that CNL graduates understand that they are not APRNs. The AACN's proposed 2015 deadline for APRNs to be prepared at the DNP level was heavily debated (Cronenwett et al., 2011) and was not realized, even though the number of DNP programs increased dramatically (from 20 programs in 2006 to 289 in 2015 with an additional 128 new DNP programs in the planning stages (AACN, 2016). Master's-level programs that prepare APRNs are continuing at this point in time. Certification The second primary criterion that must be met to be considered an APRN is professional certification for practice at an advanced level within a clinical population focus. The continuing growth of specialization has dramatically increased the amount of knowledge and experience required to practice safely in modern health care settings. National certification examinations have been developed by specialty organizations at two levels. The first level that was developed tested the specialty knowledge of experienced nurses and not knowledge at the advanced level of practice. More recently, organizations have developed APRN-specific certification examinations in a specialty. CNM and CRNA organizations were farsighted in developing certifying examinations for these roles early in their history (see Chapter 1). As regulatory groups, particularly state boards of nursing, increasingly use the certification credential as a component of APRN licensure, the certification landscape continues to change. As noted, the Consensus Model has mandated regulation of APRNs at a role and population focus level (APRN Joint Dialogue Group, 2008), accelerating the development of more broad-based APRN certification examinations. National certification at an advanced practice level is an important primary criterion for advanced practice nursing. Continuing variability in graduate curricula makes sole reliance on the criterion of graduate education insufficient to protect the public. Although standardization in educational requirements for each APRN role has improved over the last decade, it is difficult to argue that graduate education alone can provide sufficient evidence of competence for regulatory purposes. National certification examinations provide a consistent standard that must be met by each APRN to demonstrate beginning competency for an advanced level of practice in his or her role. Certification also enhances title recognition in the regulatory arena, which promotes the visibility of advanced practice nursing and enhances the public's access to APRN services. It is critically important that certifying organizations work to clarify the certification credential as appropriate only for currently practicing APRNs. Given the centrality of the direct clinical practice component to the definition of advanced practice nursing, certification examinations must establish a significant number of hours of clinical practice as a requirement for maintaining APRN certification. Some faculty and nursing leaders who do not maintain a direct clinical practice component in their positions have been allowed to sit for certification examinations and represent themselves as APRNs. Statements such as “Once a CNS, always a CNS,” which are heard with NPs and CNMs as well, perpetuate the mistaken notion that an APRN title is a professional attribute rather than a practice role. Such a misunderstanding is confusing inside and outside of nursing; by definition, these individuals are no longer APRNs. As noted, the Consensus Model focuses regulatory efforts on these broad role and population foci rather than on particular specialties, although some specialties are represented (e.g., neonatal NPs). This decision not to recognize established APRN certification examinations in specialties such as oncology or critical care for state licensure purposes has challenged the CNS role more than other APRN specialties. The American Nurses Credentialing Center (ANCC) has become the dominant certifying organization for State Board of Nursing–supported CNS examinations. The number of examination options for CNSs has significantly decreased as the Consensus Model is being implemented; the ANCC website (www.nursecredentialing.org) maintains a listing of currently available CNS examinations. It is likely that the types of APRN certification examinations offered will evolve in the Consensus Model transition period (ANCC, 2016). Even though APRN regulation is becoming more standardized, a need exists for the continued development of specialty examinations at the advanced practice nursing level, particularly for CNS specialties; as it stands now, many CNSs have to take the broad-based certification examination recognized by their state in addition to an APRN-level specialty certification examination necessary for their practice. Another unintended consequence of the limitations set by recognizing only six population foci is that educational programs have closed CNS concentrations given the lack of a sanctioned certification examination in the specialty. Although other factors also influenced these decisions, not recognizing specialty examinations for regulatory purposes is a key factor in these closures. The limited population foci sanctioned at present can be seen as a first step in standardizing regulation; the Consensus Model report noted the expectation that additional population foci would evolve. Even with these transitional issues, the Consensus Model represents an important standardization of APRN regulation and has helped cement the primary criterion of certification as a core regulatory requirement for APRN licensure. Practice Focused on Patient and Family The third primary criterion necessary for one to be considered an APRN is a practice focused on patients and their families. As noted in describing DNP graduates, the AACN DNP Essentials Task Force differentiated APRNs from other roles using this primary criterion. They noted two general role categories (AACN, 2006): “roles which specialize as an advanced practice nurse (APN) with a focus on care of individuals; and roles that specialize in practice at an aggregate, systems, or organizational level. This distinction is important as APRNs face different licensure, regulatory, credentialing, liability, and reimbursement issues than those who practice at an aggregate, systems, or organizational level” (p. 17). This criterion does not imply that direct practice is the only activity that APRNs undertake, however. APRNs also educate others, participate in leadership activities, and serve as consultants (Bryant-Lukosius et al., 2016; Ruel & Motyka, 2009); they understand and are involved in practice contexts to identify and effect needed system changes; they also work to improve the health of their specialty populations (AACN, 2006). However, to be considered an APRN role, the patient/family direct practice focus must be primary. Historically, APRN roles have been associated with direct clinical care. Recent work is solidifying this understanding. The Consensus Model (APRN Joint Dialogue Group, 2008) has made clear that the provision of direct care to individuals as a significant component of their practice is the defining factor for all APRNs. The centrality of direct clinical practice is further reflected in the core competencies presented in the next section. Why limit the definition of advanced practice nursing to roles that focus on clinical practice to patients and families? There are many reasons. Nursing is a practice profession. The nurse-patient interface is at the core of nursing practice; in the final analysis, the reason that the profession exists is to render nursing services to individuals in need of them. Clinical practice expertise in a given specialty develops from these nurse-patient encounters and lies at the heart of advanced practice nursing. Ongoing direct clinical practice is necessary to maintain and develop an APRN's expertise. Without regular immersion in practice, the cutting edge clinical acumen and expertise found in APRN practices cannot be sustained. If every specialized role in nursing were considered advanced practice nursing, the term would become so broad as to lack meaning and explanatory value. Distinguishing between APRN roles and other specialized roles in nursing can help clarify the concept of advanced practice nursing to consumers, other health care providers, and even other nurses. In addition, the monitoring and regulation of advanced practice nursing are increasingly important issues as APRNs work toward more authority for their practices (see Chapter 22). If the definition of advanced practice nursing included nonclinical roles, development of sound regulatory mechanisms would be impossible. It is critical to understand that this definition of advanced practice nursing is not a value statement but, rather, a differentiation of one group of nurses from other groups for the sake of clarity within and outside the profession. Some nurses with specialized skills in administration, research, and community health have viewed the direct practice requirement as a devaluing of their contributions. Some faculty who teach clinical nursing but do not themselves maintain an advanced clinical practice have also thought themselves to be disenfranchised because they are not considered APRNs by virtue of this primary criterion. Perhaps this problem has been exacerbated with use of the term advanced because this term can inadvertently imply that nurses who do not fit into the APRN definition are not advanced (i.e., are not as well prepared or highly skilled as APRNs). No value difference exists between nurses in non-APRN specialties and APRNs; both groups are equally important to the overall growth and strengthening of the profession. The profession must be able to differentiate its various roles without such differentiation being viewed as a disparagement of any one group. Thus it is critical to understand that this definition of advanced practice nursing is not a value statement but a differentiation of one group of nurses from other groups for the sake of clarity within and outside the profession. We must be able to say what advanced practice nursing is not, as well as what it is, if we are to clarify the concept. As the ANA (1995) has noted, all nurses—whether their focus is clinical practice, educating students, conducting research, planning community programs, or leading nursing service organizations—are valuable and necessary to the integrity and growth of the larger profession. However, all nurses, particularly those with advanced degrees, are not the same, nor are they necessarily APRNs. Historically, the profession has had difficulty differentiating itself and has struggled with the prevailing lay notion that “a nurse is a nurse is a nurse.” This antiquated view does not match the reality of the health care arena, nor does it celebrate the diverse contributions of all the various nursing roles and specialties. Seven Core Competencies of Advanced Practice Nursing Direct Clinical Practice: The Central Competency As noted earlier, the primary criteria are necessary but insufficient elements of the definition of advanced practice nursing. Advanced practice nursing is further defined by a set of seven core competencies that are enacted in each APRN role. The first core competency of direct clinical practice is central to and informs all of the others (see Fig. 3.2). In one sense, it is “first among equals” of the seven core competencies that define advanced practice nursing. Although APRNs do many things, excellence in direct clinical practice provides the foundation necessary for APRNs to execute the other competencies, such as consultation, guidance and coaching, and leadership within organizations. FIG 3.2 Central competency of advanced practice nursing. However, clinical expertise alone should not be equated with advanced practice nursing. The work of Patricia Benner and colleagues (Benner, 1984; Benner, Hooper-Kyriakidis, & Stannard, 1999; Benner, Tanner, & Chesla, 1996) is a major contribution to an understanding of clinically expert nursing practice. These researchers extensively studied expert nurses in acute care clinical settings and described the engaged clinical reasoning and domains of practice seen in clinically expert nurses. Although some of the participants in this research were APRNs (in the most recent report [Benner et al., 1999], 16% of the nurse participants were APRNs), most were nurses with extensive clinical experience who did not have APRN preparation. Calkin (1984) has characterized these latter nurses as “experts by experience.” (See Chapter 2 for a discussion of Calkin's conceptual differentiation between levels of nursing practice.) Benner and colleagues did not discuss differences in the practices of APRNs as compared with other nurses that they have studied. They stated that “ ‘Expert’ is not used to refer to a specific role such as an advanced practice nurse. Expertise is found in the practice of experienced clinicians and advanced practice nurses” (Benner et al., 1999, p. 9). Although clinical expertise is a central ingredient of an APRN's practice, the direct care practice of APRNs is distinguished by six characteristics: (1) use of a holistic perspective, (2) formation of therapeutic partnerships with patients, (3) expert clinical performance, (4) use of reflective practice, (5) use of evidence as a guide to practice, and (6) use of diverse approaches to health and illness management (see Chapter 7). These characteristics help distinguish the practice of the expert by experience from that of the APRN. APRN clinical practice is also informed by a population focus (AACN, 2006) because APRNs work to improve the care for their specialty patient population, even as they care for individuals within the population. As noted, experiential knowledge and graduate education combine to develop these characteristics in an APRN's clinical practice. It is important to note that the “three Ps” that form core courses in all APRN programs (pathophysiology, pharmacology, and physical assessment) are not separate competencies in this understanding, but provide baseline knowledge and skills to support the direct clinical practice competency. The specific content of the direct practice competency differs significantly by specialty. For example, the clinical practice of a CNS dealing with critically ill children differs from the expertise of an NP managing the health maintenance needs of older adults or a CRNA administering anesthesia in an outpatient surgical clinic. In addition, the amount of time spent in direct practice differs by APRN specialty. CNSs in particular may spend most of their time in activities other than direct clinical practice (see Chapter 14). Thus it is important to understand this competency as a central defining characteristic of advanced practice nursing rather than as a particular skill set or expectation that APRNs only engage in direct clinical practice. Additional Advanced Practice Nurse Core Competencies In addition to the central competency of direct clinical practice, six additional competencies further define advanced practice nursing regardless of role function or setting. As shown in Fig. 3.3, these additional core competencies are as follows: FIG 3.3 Core competencies of advanced practice nursing. • Guidance and coaching • Consultation • Evidence-based practice • Leadership • Collaboration • Ethical decision making These competencies have repeatedly been identified as essential features of advanced practice nursing. In addition, each role is differentiated by some unique competencies (see the specific role chapters in Part III of this text). The nature of the patient population receiving APRN care, organizational expectations, emphasis given to specific competencies, and practice characteristics unique to each role distinguish the practice of one APRN group from others. Each APRN role organization publishes role-specific competencies on their websites: the National Association of Clinical Nurse Specialists (NACNS) for CNSs (www.nacns.org); the National Organization of Nurse Practitioner Faculties (NONPF) for NPs (www.nonpf.org); the ACNM for CNMs (www.acnm.org); and the American Association of Nurse Anesthetists for CRNAs (www.aana.com). There is a dynamic interplay between the core APRN competencies and each role; rolespecific expectations grow out of the core competencies and similarly serve to inform them as APRNs practice in a changing health care system. In addition, competencies promoted by other professional groups become important to the understanding of advanced practice nursing; for example, the Interprofessional Education Collaborative competencies on interprofessional practice are helping to shape the understanding of collaboration (Interprofessional Education Collaborative Expert Panel, 2011; see Chapter 12). It is also important to understand that each of the competencies described in Part II of this text have specific definitions in the context of advanced practice nursing. For example, leadership has clinical, professional, and systems expectations for the APRN that differ from those for a nurse executive or staff nurse. These unique definitions of each competency help distinguish practice at the advanced level. Similarly, certain competencies are important components of other specialized nursing roles. For example, collaboration and consultation are important competencies for nursing administrators. The uniqueness of advanced practice nursing is seen in the synergistic interaction between direct clinical practice and this constellation of competencies. In Fig. 3.3, the openings between the central practice competency and these additional competencies represent the fact that the APRN's direct practice skill interacts with and informs all the other competencies. For example, APRNs consult with other providers who seek their practice expertise to plan care for specialty patients. They are able to provide expert guidance and coaching for patients going through health and illness transitions because of their direct practice experience and insight. The core competencies are not unique to APRN practices. Physicians and other health care providers may have developed some of them. Experienced staff nurses may master several of these competencies with years of practice experience. These nurses are seen as exemplary performers and are often encouraged to enter graduate school to become APRNs. What distinguishes APRN practice is the expectation that every APRN's practice encompasses all these competencies and seamlessly blends them into daily practice encounters. This expectation makes APRN practice unique among that of other providers. These complex competencies develop over time. No APRN emerges from a graduate program fully prepared to enact all of them. However, it is critical that graduate programs provide exposure to each competency in the form of didactic content and practical experience so that new graduates can be prepared to utilize them at the basic core level, be given a base on which to build their practices, and be tested for initial credentialing. These key competencies are described in detail in subsequent chapters and are not further elaborated here. Scope of Practice The term scope of practice refers to the legal authority granted to a professional to provide and be reimbursed for health care services. The ANA (2015b) defined the scope of nursing practice as “… the description of the who, what, where, when, why, and how of nursing practice” (p. 2). This authority for practice emanates from many sources, such as state and federal laws and regulations, the profession's code of ethics, and professional practice standards. For all health care professionals, scope of practice is most closely tied to state statutes; for nursing in the United States, these statutes are the nurse practice acts of the various states. As previously discussed, APRN scope of practice is characterized by specialization; expansion of services provided, including diagnosing and prescribing; and autonomy to practice (NCSBN, 2008). The scopes of practice also differ among the various APRN roles; various APRN organizations have provided detailed and specific descriptions for their particular role. Carving out an adequate scope of APRN practice authority has been a historic struggle for most of the advanced practice groups (see Chapter 1), and this continues to be a hotly debated issue among and within the health professions. Significant variability in state practice acts continues, such that APRNs can perform certain activities in some states, notably prescribing certain medications and practicing without physician supervision, but may be constrained from performing these same activities in other states (NCSBN, 2016). The Consensus Model's proposed regulatory language can be used by states to achieve consistent scope of practice language and standardized APRN regulation (APRN Joint Dialogue Group, 2008). Although almost 2 decades old, a report by the Pew Health Professions Commission (Finocchio, Dower, Blick, Gragnola, & Taskforce on Health Care Workforce Regulation, 1998) remains relevant today. The Taskforce noted that the tension and turf battles between professions and the increased legislative activities in this area “clog legislative agendas across the country.” These battles are costly and time-consuming and lawmakers' decisions related to scope of practice are frequently distorted by campaign contributions, lobbying efforts, and political power struggles rather than being based on empirical evidence. More recently, while the Institute of Medicine (IOM) has reported that progress continues on a state-by-state basis in achieving full practice authority for APRNs, there are still many states where APRNs have reduced or restricted practice authority (National Academies of Sciences, Engineering, & Medicine, 2016) (see Chapter 22 for further discussion). In addition, the IOM highlights the fact that medical staff member and hospital privileging criteria are inconsistent due to state laws as well as business preferences. Opposition by some physician associations and physicians is ongoing and can be a significant barrier. Much work remains to be done. The IOM recommends that the coalition of stakeholders to remove these barriers needs to be expanded and diversified to increase collaboration in improving health care for patients (National Academies of Sciences, Engineering, & Medicine, 2016). Differentiating Advanced Practice Roles: Operational Definitions of Advanced Practice Nursing As noted earlier, it is critical to the public's understanding of advanced practice nursing that APRN roles and resulting job titles reflect actual practices. Because actual practices differ, job titles should differ. The following corollary is also true—if the actual practices do not differ, the job titles should not differ. For example, some institutions have retitled their CNSs clinical coordinators or clinical educators, even though these APRNs are practicing consistently with the practices of a CNS. This change in job title renders the CNS practice less clearly visible in the clinical setting and thereby obscures CNS role clarity. As noted, differences among roles must be clarified in ways that promote understanding of advanced practice nursing, and the Consensus Model (APRN Joint Dialogue Group, 2008) clarifies appropriate titling for APRNs. Workforce Data It is difficult to obtain accurate numbers for APRNs by role, particularly for those prepared as CNSs. The US Bureau of Labor Statistics has separate classifications for NPs, CRNAs, and CNMs in their Standard Occupational Classification listing, so some data are collected when the Bureau does routine surveys. However, CNSs are not listed as a separate role in the classification system; rather the role is subsumed under the general registered nurse (RN) classification. The Bureau of Labor Statistics has refused to add a CNS classification despite repeated attempts to convince them otherwise. Therefore the latest APRN role numbers are based on the respective organizational data for consistency (Table 3.1). TABLE 3.1 It is essential to have accurate tracking of APRN numbers by distinct role as well as by geographic distribution and basic demographic statistics. Gathering data only on select APRN roles or as subcategories of the RN role diminishes the profession's ability to actively and appropriately advocate for patients on a national level for needed care that can best be provided by APRNs. Four Established Advanced Practice Nurse Roles Advanced practice nursing is applied in the four established roles and in emerging roles. These APRN roles can be considered to be the operational definitions of the concept of advanced practice nursing. Although each APRN role has the common definition, primary criteria, and competencies of advanced practice nursing at its center, each has its own distinct form. Some of the distinctive features of the various roles are listed here. Differences and similarities among roles are further explored in Part III of this text. The NACNS (2004) has distinguished CNS practice by characterizing “spheres of influence” in which the CNS operates. These include the patient/client sphere, the nurses and nursing practice sphere, and the organization/system sphere (see Chapter 14). A CNS is first and foremost a clinical expert who provides direct care to patients with complex health problems. CNSs not only learn consultation processes, as do other APRNs, but also function as formal consultants to nursing staff and other care providers within their organizations. Developing, supporting, and educating nursing staff and other interprofessional staff to improve the quality of patient care is a core part of the nurses and nursing practice sphere. Managing system change in complex organizations to build teams and improve nursing practices, and effecting system change to enable better advocacy for patients, are additional role expectations of the CNS. Expectations regarding sophisticated evidence-based practice activities have been central to this role since its inception. NPs, whether in primary care or acute care, possess advanced health assessment, diagnostic, and clinical management skills that include pharmacology management. Their focus is expert direct care, managing the health needs of individuals and their families. Incumbents in the classic NP role provide primary health care focused on wellness and prevention; NP practice also includes caring for patients with minor, common acute conditions and stable chronic conditions (see Chapter 15). The acute care NP (ACNP) brings practitioner skills to a specialized patient population within the acute care setting. The ACNP's focus is the diagnosis and clinical management of acutely or critically ill patient populations in a particular specialized setting. Acquisition of additional medical diagnostic and management skills, such as interpreting computed tomography and magnetic resonance imaging scans, inserting chest tubes, and performing lumbar punctures, also characterize this role (see Chapter 16). The CNM (see Chapter 17) has advanced health assessment and intervention skills focused on women's health and childbearing. CNM practice involves independent management of women's health care. CNMs focus particularly on pregnancy, childbirth, the postpartum period, and neonatal care, but their practices also include family planning, gynecologic care, primary health care for women through menopause, and treatment of male partners for sexually transmitted infections (ACNM, 2012). The CNM's focus is on providing direct care to a select patient population. CRNA practice (see Chapter 18) is distinguished by advanced procedural and pharmacologic management of patients undergoing anesthesia. CRNAs practice independently, in collaboration with physicians, or as employees of a health care institution. Like CNMs, their primary focus is providing direct care to a select patient population. Both CNM and CRNA practices are also distinguished by well-established national standards and certification examinations in their specialties. These differing roles and their similarities and distinctions are explored in detail in subsequent chapters. It is expected that other roles may emerge as health care continues to change and new opportunities become apparent. This brief discussion underscores the rich and varied nature of advanced practice nursing and the necessity for retaining and supporting different APRN roles and titles in the health care marketplace. At the same time, the consistent definition of advanced practice nursing described here undergirds each of these roles, as will be seen in Part III of this text. Critical Elements in Managing Advanced Practice Nursing Environments The health care arena is increasingly fluid and changeable; some would even say it is chaotic. Advanced practice nursing does not exist in a vacuum or a singular environment. Rather, this level of practice occurs in an increasing variety of health care delivery environments. These diverse environments are complex admixtures of interdependent elements, as noted in Fig. 3.4. The term environment refers to any milieu in which an APRN practices, ranging from a community-based rural health care practice for a primary care NP to a complex tertiary health care organization for an ACNP. Certain core features of these environments dramatically shape advanced practice and must be managed by APRNs in order for their practices to survive and thrive (Fig. 3.4). Although not technically part of the core definition of advanced practice nursing, these environmental features are included here to frame the understanding that APRNs must be aware of these key elements in any practice setting. Furthermore, APRNs must be prepared to contend with and shape these aspects of their practice environment to be able to enact advanced practice nursing fully. FIG 3.4 Critical elements in advanced nursing practice environments. The environmental elements that affect APRN practice include the following: • Managing reimbursement and payment mechanisms • Dealing with marketing and contracting considerations • Understanding legal, regulatory, and credentialing requirements • Understanding and shaping health policy considerations • Strengthening organizational structures and cultures to support advanced practice nursing • Enabling outcome evaluation and performance improvement With the exception of organizational structures and cultures, Part IV of this text explores these elements in depth. Discussion of organizational considerations is presented in Chapter 4 and woven throughout the chapters in Part III. Common to all these environmental elements is the increasing use of technology and the need for APRNs to master various new technologies to improve patient care and health care systems. The ability to use information systems and technology and patient care technology is an essential element of master's and DNP curricula (AACN, 2006, 2011). Electronic technology in the form of electronic health records, coding schemas, communications, Internet use, and provision of care across state lines through telehealth practices is changing health care practice. These changes, in turn, are reshaping all seven APRN core competencies. Proficiency in the use of new technologies is increasingly necessary to support clinical practice, implement quality improvement initiatives, and provide leadership to evaluate outcomes of care and care systems (see Chapter 24). Managing the business and legal aspects of practice is increasingly critical to APRN survival in the competitive health care marketplace. All APRNs must understand current reimbursement issues, even as changes related to the Patient Protection and Affordable Care Act (2010) are being debated. Payment mechanisms and legal constraints must be managed, regardless of setting. Given the increasing competition among physicians, APRNs, and nonphysician providers, APRNs must be prepared to market their services assertively and knowledgeably. Marketing oneself as a new NP in a small community may look different from marketing oneself as a CNS in a large health system, but the principles are the same. Marketing considerations often include the need to advocate for and actively create positions that do not currently exist. Contract considerations are much more complex at the APRN level and all APRNs, whether newly graduated or experienced, must be prepared to enter into contract negotiations. Health policy at the state and federal levels is an increasingly potent force shaping advanced practice nursing; regulations and policies that flow from legislative actions can enable or constrain APRN practices. Variations in the strength and number of APRNs in various states attest to the power of this environmental factor. Organizational structures and cultures, whether those of a community-based practice or a hospital unit, are also important facilitators of or barriers to advanced practice nursing; APRN students must learn to assess and intervene to build organizations and cultures that strengthen APRN practice. Finally, APRNs are accountable for the use of evidence-based practice to ensure positive patient and system outcomes. Measuring the favorable impact of advanced practice nursing on these outcomes and effecting performance improvements are essential activities that all APRNs must be prepared to undertake because continuing to demonstrate the value of APRN practice is a necessity in chaotic practice environments. Special mention must be made of health care quality. As quality concerns have escalated, more attention is being focused on quality metrics for all settings (see Chapter 24). Reimbursement is being increasingly tied to quality metrics, with higher expectations for transparency of quality outcomes by providers. APRNs are an important part of the solution to ensuring quality outcomes for their specialty populations. Quality is not itself a competency or an environmental element, but it is an important feature that should be evident in the processes that APRNs use and the outcomes that they achieve. For example, coaching for wellness should demonstrate the quality processes of a therapeutic nurse-patient relationship and the patient being a partner with the APRN in achieving wellness outcomes. The importance of APRN involvement in quality initiatives can be seen in the work of the Nursing Alliance for Quality Care, a national partnership of organizations, consumers, and other stakeholders in the safety and quality arena (http://www.naqc.org). Implications of the Definition of Advanced Practice Nursing A number of implications for education, regulation and credentialing, practice, and research flow from this understanding of advanced practice nursing. The Consensus Model (APRN Joint Dialogue Group, 2008) makes the important point that effective communication between legal and regulatory groups, accreditors, certifying organizations, and educators (licensing, accreditation, certification, and education [LACE]) is necessary to advance the goals of advanced practice nursing. Decisions made by each of these groups affect and are affected by all the others. Historically, advanced practice nursing has been hampered by the lack of consensus in APRN definition, terminology, educational and certification requirements, and regulatory approaches. The Consensus Model process, by combining stakeholders from each of the LACE areas, took a giant step forward toward the profession's achieving needed consensus on APRN practice, education, certification, and regulation. Implications for Advanced Practice Nursing Education Graduate programs should provide anticipatory socialization experiences to prepare students for their chosen APRN role. Graduate experiences should include practice in all the competencies of advanced practice nursing, not just direct clinical practice. For example, students who have no theoretical base or guided practice experiences in consultative skills or clinical, professional, and systems leadership will be ill-equipped to demonstrate these competencies on assuming a new APRN role. In addition, APRN students need to understand the critical elements in health care environments, such as the business aspects of practice and health care policy that must be managed if their practices are to survive and grow. All APRN roles require at least a specialty master's education; master's programs are continuing even as the DNP degree is being developed in many institutions. The profession has embraced a wide variety of graduate educational models for preparing APRNs, including direct-entry programs for non-nurse college graduates and RN-to-MSN programs. However, three of the four APRN professional organizations have endorsed doctoral preparation as entry into APRN practice (the American Association of Nurse Anesthetists by the year 2025 [2007], the NACNS by the year 2030 [2015], and the NONPF [2015]). Ensuring quality and standardization of APRN education in the various specialties is imperative if the profession is to guarantee a highly skilled, uniformly educated APRN workforce to the public. The definition of advanced practice nursing used here can serve as a guide for developing quality courses and clinical practice experiences that prepare APRN students to practice at an advanced level. It is imperative that nursing leaders and DNP faculty continue to provide increased clarity for the terms advanced nursing practice and advanced practice nursing. The differences between the two, despite being significant particularly in the practice setting, are easily lost on the majority of RNs and even non-APRN DNP graduates. Lack of clarity about this distinction has created ongoing problems as DNP graduates prepared in non-APRN roles confuse their combined graduate preparation and their RN clinical experience with being an APRN. This type of confusion about roles within nursing only perpetuates the ongoing lack of clarity when communicating with physicians and policymakers (Carter et al., 2013; Carter, Lavis, & MacDonald-Rencz, 2014) and compromises the progress that APRNs have made in the practice arena. Implications for Regulation and Credentialing Significant progress has been made toward an integrative view of APRN regulation over the past decade, culminating in the LACE regulatory framework detailed in the Consensus Model. In particular, the primary criteria of graduate education, advanced certification, and focus on direct clinical practice for all APRN roles proposed in Hamric's definition have been affirmed as the key elements in regulating and credentialing APRNs (APRN Joint Dialogue Group, 2008). Such internal cohesion can go a long way toward removing barriers to the public's access to APRN care. The Consensus Model has been an important unifying force within the APRN community. The regulatory clarity in this document has increasingly been seen in other national statements, and the work was highlighted in the IOM report on The Future of Nursing (IOM, 2011). The NCSBN has embarked on the “APRN Campaign for Consensus,” a nationwide effort to have this model enacted in all the states. However, as of 2017, only 16 states have fully implemented the Consensus Model into legislation (NCSBN, 2017). The IOM report also has given rise to action coalitions, funded by the AARP Foundation and the Robert Wood Johnson Foundation, in numerous states (Campaign for Action, 2017). The Campaign for Action has a dual focus, implementing solutions to the challenges facing the nursing profession and strengthening nurse-based approaches to transform how Americans receive quality health care. Although the Campaign for Action is broader in scope than just advanced practice nursing, many of the solutions for transforming health care involve APRNs being able to practice to the full extent of their education. It is critically important for all APRNs to be aware of and involved in these efforts. One implication for credentialing flows from the diverse specialty and role base of advanced practice nursing. APRNs must practice and be certified in the specific population focus and role for which they have been educated. APRNs who wish to change their specialty, population focus, or APRN role need to return to school for education targeted to that area. The days are past when a primary care NP could take a job in a specialized acute care practice without further education to prepare for that specialty. This issue of aligning APRN job expectations with education and certification is not always well understood by practice environments, educators, or even APRNs themselves. However, the need to ensure congruence among particular APRN specialties and roles and education, certification, and subsequent practice has been identified by regulators, and more stringent regulations regarding this issue have been promulgated (NCSBN, 2008). Implications for Research As noted in Chapter 10, one of the core competencies of advanced practice nursing is the use of evidence-based practice in an APRN's practice and in changing the practice environment to incorporate the use of evidence. The practice doctorate initiative identified the increased need for leadership in evidence-based practice and for application of knowledge to solve practice problems and improve health outcomes as reasons for moving to the DNP degree for APRN practice (AACN, 2006). If research is to be relevant to health care delivery and to nursing practice at all levels, APRNs must be involved. APRNs need to recognize the importance of advancing the profession's and health care system's knowledge about effective patient care practices and to realize that they are a vital link in building and translating this knowledge into clinical practice. Related to this research involvement is the necessity for more research differentiating basic and advanced practice nursing and identifying the patient populations that benefit most from APRN intervention. For example, there is compelling empirical evidence that APRNs can effectively manage chronic disease—preventing or mitigating complications, reducing rehospitalizations, and increasing patients' quality of life. This evidence is presented in the chapters in Part III of this text and in Chapter 23. Linking advanced practice nursing to specific patient outcomes remains a major research imperative for this century. It is interesting to note the increasing research being conducted in international settings as more countries implement advanced practice nursing and study the effectiveness of these new practitioners; discussions of this research are woven throughout the chapters of this book. Similarly, research is needed on the outcomes of the different APRN educational pathways in terms of APRN graduate experiences and patient outcomes. Such data would be invaluable in continuing to refine advanced practice education. Outcomes achieved by graduates from DNP programs need similar study in comparison to master's- level APRN graduates; in critiquing the need for the DNP degree, Fulton and Lyon (2005) noted the absence of research data on whether there are weaknesses in current master's-level graduates. Finally, it is incumbent upon DNP faculty to ensure that APRNs understand their role in evidence-based practice vis-à-vis research. In fact, faculty themselves continue to struggle with knowledge and understanding of evidence-based practice and its use in the completion of the scholarly DNP project (AACN, 2015; Dols, Hernandez, & Miles, 2017). Translational, evidence-based practice change, and quality improvement projects are the proper foci for DNP projects; such projects require a complex skill set that is the focus of DNP evidence-based practice courses. DNP students are not sufficiently educated in the particulars of the formal research process to be prepared to conduct independent research successfully, and faculty have an important responsibility to assist the student to identify an appropriate topic. Unfortunately, it is not uncommon to encounter APRN DNP projects that are not an implementation of evidence-based practice or a clinical change project to bring research evidence to influence practice, but rather involve the conduct of a research study. The DNP-prepared APRN is an evidence-based practice expert who evaluates and generates internal evidence, translates research into sustainable practice changes, and uses research to make practice decisions that improve the quality of patient care (AACN, 2006; Melnyk, 2016). Without this important understanding, nursing runs the risk of implying that advancing the science of nursing through research no longer requires PhD preparation. Such a misunderstanding could lead practice institutions to hire DNP graduates with the intention that they conduct rigorous independent research. It could also substantially delay the translation of research findings into clinical practice. Implications for Practice Environments Because of the centrality of direct clinical practice, APRNs must hold onto and make explicit their direct patient care activities. They must also articulate the importance of this level of care for patients. In addition, it is important to identify those patients who most need APRN services and ensure that they receive this care. APRN roles require considerable autonomy and authority to be fully enacted. Practice settings have not always structured APRN roles to allow sufficient autonomy or accountability for achievement of the patient and system outcomes that are expected of advanced practitioners. It is equally important to emphasize that APRNs have expanded responsibilities—expanded authority for practice requires expanded responsibility for practice. APRNs must demonstrate a higher level of responsibility and accountability if they are to be seen as legitimate providers of care and full partners on provider teams responsible for patient populations. This willingness to be accountable for practice will also promote consumers' and policymakers' perceptions of APRNs as credible providers in line with physicians. The APRN leadership competency mandates that APRNs serve as visible role models and mentors for other nurses (see Chapter 11). Leadership is not optional in APRN practice; it is a requirement. APRNs must be a visible part of the solution to the health care system's problems. For this goal to be realized, each APRN must practice leadership in his or her daily activities. In practice environments, APRNs need structured time and opportunities for this leadership, including mentoring activities with new nurses. New APRNs require a considerable period of role development before they can master all the components and competencies of their chosen role, which has important implications for employers of new APRNs. Employers should provide experienced preceptors, some structure for the new APRN, and ongoing support for role development (see Chapter 4 for further recommendations). As a result of government titling, it is becoming common in the practice setting to label APRNs (as well as physician assistants) as “mid-level providers.” The very use of this term for an APRN implies a hierarchical (and therefore a “less than”) structure for all of nursing. If the APRN is “mid-level,” then the implication is that the physician is at the top and the RN is thus positioned at the bottom of the care provider structure (Boyle, 2011). This is contrary to the reality that all health care providers bring unique and valued expertise to the care of patients; the professional leading the care at any given point in a patient's health encounter is dependent on the needs of the patient and the provider with the corresponding expertise. It is important that APRNs distinguish their roles from this unfortunately named category. Finally, APRN roles must be structured in practice environments to allow APRNs to enact advanced nursing skills rather than simply substitute for physicians. It is certainly necessary for APRNs to gain additional skills in medical diagnosis and therapeutic interventions, including the knowledge needed for prescriptive authority. However, advanced practice nursing is a value-added complement to medical practice, not a substitute for it. This is particularly an imperative in the primary care arena; it may well be that substituting APRNs for physicians in classic, medically driven primary care configurations is not the best use of APRN skills. Because APRN competencies include those of partnering with patients, use of evidence, and coaching skills, APRNs may be more effectively used in wellness programs, working with chronically ill patients to strengthen their self-management and adherence, and designing and implementing educational programs for patients with complex management needs. New sustainable business models are needed that are more collaborative and configure teams in innovative ways to minimize fragmentation of care and make the best use of the APRN as a value-added complement to the traditional medical team. As physician shortages increase, particularly the number of physicians prepared in family practice and the new hospitalist practices, this distinction between advanced practice nursing and medical practice must be clear in the minds of employers, insurers, and APRNs themselves. As advanced practice nursing evolves, it is becoming clear that APRNs represent a choice and an alternative for patients seeking care. Consequently, understanding what APRNs bring to health care must be articulated to multiple stakeholders to enable informed patient choice. A competency-based definition of advanced practice nursing aids in this articulation, so that APRNs are not just seen as physician substitutes. Conclusion Since the first edition of this text in 1996, substantial progress has been made toward clarifying the definition of advanced practice nursing. This progress is enabling APRNs, educators, administrators, and other nursing leaders to be clear and consistent about the definition of advanced practice nursing so that the profession speaks with one voice. This is a critical juncture in the evolution of advanced practice nursing as national attention on nursing and recommendations for nursing's central role in redesigning the health care system are increasing. APRNs must continue to clarify that the advanced practice of nursing is not the junior practice of medicine but represents an important alternative practice that complements rather than competes with medical practice. In some cases, patients need advanced nursing and not medicine; identifying these situations and matching APRN resources to patients' needs are important priorities for transforming the current health care system. APRNs must be able to articulate their defining characteristics clearly and forcefully so that their practices will survive and thrive amidst continued cost cutting in the health care sector. For a profession to succeed, it must have internal cohesion and external legitimacy, and it must have them at the same time (Safriet, 1993). Clarity about the core definition of advanced practice nursing and recognition of the primary criteria and competencies necessary for all APRNs enhance nursing's internal cohesion. At the same time, clarifying the differences among APRNs and showcasing their important roles in the health care system enhance nursing's external legitimacy. Key Summary Points ■ The advanced practice of nursing is not the junior practice of medicine; advanced practice nursing is a complement to, not a substitution for, medical practice. ■ There is a clear and distinct difference between the terms advanced practice nursing and advanced nursing practice, and this difference needs to continue to be clearly elucidated, especially as the terms are used on a global basis. ■ The three primary criteria of an earned graduate degree with a concentration in an advanced practice nursing role and population focus, national certification at an advanced level, and a practice focused on patients and their families are necessary but not sufficient to define advanced practice nursing. ■ The DNP is an academic degree, not a role. ■ All APRNs share the same core criteria and competencies, although the actual clinical skill set varies, depending on the needs of the APRN's specialty patient population. References American Association of Colleges of Nursing. 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Mackavey “Where the needs of the world and your talents cross, there lies your vocation.” —Aristotle CHAPTER CONTENTS Perspectives on Advanced Practice Nurse Role Development, 81 Novice-to-Expert Skill Acquisition Model, 81 Role Concepts and Role Development Issues, 83 Role Ambiguity, 83 Role Incongruity, 84 Role Conflict, 85 Role Transitions, 88 Advanced Practice Nurse Role Acquisition in Graduate School, 88 Strategies to Facilitate Role Acquisition, 90 Advanced Practice Nursing Role Implementation at Work, 94 Strategies to Facilitate Role Implementation, 98 International Experiences With Advanced Practice Nurse Role Development and Implementation: Lessons Learned and a Proposed Model for Success, 100 Facilitators and Barriers in the Work Setting, 102 Continued Advanced Practice Nurse Role Evolution, 103 Evaluation of Role Development, 104 Conclusion, 106 Key Summary Points, 107 This chapter explores the complex processes of advanced practice registered nurse (APRN) role development, with the objectives of providing the following: (1) an understanding of related concepts and research; (2) anticipatory guidance for APRN students; (3) role facilitation strategies for new APRNs, APRN preceptors, faculty, administrators, and interested colleagues; and (4) guidelines for continued role evolution. This chapter consolidates literature from all the APRN specialties—including clinical nurse specialists (CNSs), nurse practitioners (NPs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs)—to present a generic process relevant to all APRN roles. Some of this literature is foundational to understanding issues of role development for all APRN roles and, although dated, remains relevant. This chapter has been expanded to include international APRN role development experiences. To reflect the literature indicating that APRN role transition occurs as two distinct processes, the discussion is separated into (1) the educational component of APRN role acquisition and (2) the occupational or work component of role implementation. This division in the process of role development is intended to clarify and distinguish the changes occurring during the role transitions experienced during the educational period (role acquisition) and the changes occurring during the actual performance of the role after program completion (role implementation). Strategies for enhancing APRN role development are described. The chapter concludes with summary comments and suggestions to facilitate future APRN role development and evolution. Role development in advanced practice nursing is described here as a process that evolves over time. The process is more than socializing and taking on a new role. It involves transforming one's professional identity (Benner, 2011; Jarvis-Selinger, Pratt, & Regehr, 2012) and the progressive development of the seven core advanced practice competencies (see Chapter 3). The scope of nursing practice has expanded and contracted in response to societal needs, political forces, and economic realities (Levy, 1968; Safriet, 1992; see Chapter 1). Historical evidence suggests that the expanded role of the 1970s was common nursing practice during the early 1900s among public health nurses (DeMaio, 1979; see Chapter 1). However, the core of nursing is not defined by the tasks nurses perform. This task-oriented perspective is inadequate and disregards the complex nature of nursing. Perspectives on Advanced Practice Nurse Role Development Professional role development is a dynamic ongoing process that, once begun, spans a lifetime. The concept of graduation as commencement, whereby one's career begins on completion of a degree, is central to understanding the evolving nature of professional roles in response to personal, professional, and societal demands (Gunn, 1998). Professional role development literature in nursing is abundant and complex, involving multiple component processes, including the following: (1) aspects of adult development; (2) development of clinical expertise; (3) modification of self-identity through initial socialization in school; (4) embodiment of ethical comportment (Benner, Sutphen, Leonard, & Day, 2010); (5) development and integration of professional role components; and (6) subsequent resocialization in the work setting. Similar to socialization for other professional roles, such as those of attorney, physician, teacher, and social worker, the process of becoming an APRN involves aspects of adult development and professional socialization. The professional socialization process in advanced practice nursing involves identification with and acquisition of the behaviors and attitudes of the advanced practice group to which one aspires (Waugaman & Lu, 1999, p. 239). This includes learning the specialized language, skills, and knowledge of the particular APRN group, internalizing its values and norms, and incorporating these into one's professional nursing identity and other life roles (Cohen, 1981). Novice-to-Expert Skill Acquisition Model Acquisition of knowledge and skill occurs in a progressive movement through the stages of performance from novice to expert, as described by Dreyfus and Dreyfus (1986, 2009), who studied diverse groups, including pilots, chess players, and adult learners of second languages. The skill acquisition model has broad applicability and can be used to understand many different skills, ranging from playing a musical instrument to writing a research grant. The most widely known application of this model is Benner's (1984) observational and interview study of clinical nursing practice situations from the perspective of new nurses and their preceptors in hospital nursing services. Although this study included several APRNs, it did not specify a particular education level as a criterion for expertise. As noted in Chapter 3, there has been some confusion about this criterion. The skill acquisition model is a situation-based model, not a trait model. Therefore, the level of expertise is not an individual characteristic of a particular nurse but is a function of the nurse's familiarity with a particular situation in combination with his or her educational background. This model could be used to study the level of expertise required for other aspects of advanced practice, including guidance and coaching, consultation, collaboration, evidence-based practice, ethical decision making, and leadership. Fig. 4.1 shows a typical APRN role development pattern in terms of this skill acquisition model. A major implication of the novice-toexpert model for advanced practice nursing is the claim that even experts can be expected to perform at lower skill levels when they enter new situations or positions. Hamric and Taylor's report (1989) that an experienced CNS starting a new position experiences the same role development phases as a new CNS graduate, only over a shorter period, supports this claim. The same pattern can be expected with new Doctor of Nursing Practice (DNP) graduates; they experience similar role development phases upon assuming a new DNP position, but they go through phases more quickly because they are informed by broader education and experience (Glasgow & Zoucha, 2011). FIG 4.1 Typical APRN role development pattern. 1a, APRN students may begin graduate school as proficient or expert nurses. 1b, Some enter as competent RNs, with limited practice experience. Depending on previous background, the new APRN student will revert to novice level or advanced beginner level on assuming the student role. 2, A direct-entry APRN student or non-nurse college graduate student with no experience would begin the role transition process at the novice level. 3, The graduate from an APRN program is competent as an APRN student but has no experience as a practicing APRN. 4, A limbo period is experienced while the APRN graduate searches for a position and becomes certified. 5, The newly employed APRN reverts to the advanced beginner level in the new APRN position as the role trajectory begins again. 6, Some individuals remain at the competent level. There is a discontinuous leap from the competent to the proficient level. 7, Proficiency develops only if there is sufficient commitment and involvement in practice along with embodiment of skills and knowledge. 8, Expertise is intuitive and situation specific, meaning that not all situations will be managed expertly. (See text for details.) Note: Readers may refer to the Dreyfus skill acquisition model for further details (Benner, 1984; Benner, Tanner, & Chesla, 2009; Dreyfus & Dreyfus, 1986, 2009). For the purpose of illustration, this figure is more linear than the individualized role development trajectories that actually occur. The overall trajectory expected during APRN role development is shown in Fig. 4.1; however, each APRN experiences a unique pattern of role transitions and life transitions concurrently. For example, a professional nurse who functions as a mentor for new graduates may decide to pursue an advanced degree as an APRN. As an APRN graduate student, she or he will experience the challenges of acquiring a new role, the anxiety associated with learning new skills and practices, and the dependency of being a novice. At the same time, if this nurse continues to work as a registered nurse, his or her functioning in this work role will be at the competent, proficient, or expert level, depending on experience and the situation. On graduation, the new APRN may experience a limbo period during which she or he is no longer a student and not yet an APRN, while searching for a position and meeting certification requirements (see Chapter 22). Once in a new APRN position, this nurse may experience a return to the advanced beginner stage as he or she proceeds through the phases of role implementation. Even after making the transition to an APRN role, progression in role implementation is not a linear process. As Fig. 4.1 indicates, there are discontinuities, with movement back and forth as the trajectory begins again. Years later, the APRN may decide to pursue yet another APRN role or obtain a DNP. The processes of role acquisition, role implementation, and novice-to-expert skill development will again be experienced— although altered and informed by previous experiences—as the postgraduate student acquires additional skills and knowledge. Role development involves multiple, dynamic, and situational processes, with each new undertaking being characterized by passage through earlier transitional phases and with some movement back and forth, horizontally or vertically, as different career options are pursued. Direct-entry students who are non-nurse college graduates and APRN students with little or no experience as nurses before entry into an APRN graduate program would be expected to begin their APRN role development at the novice level (see Fig. 4.1). Some evidence indicates that although these inexperienced nurse students may lack the intuitive sense that comes with clinical experience, they avoid the role confusion associated with letting go of the traditional registered nurse (RN) role that is commonly reported with experienced nurse students (Heitz, Steiner, & Burman, 2004). This finding has implications for APRN education as the profession moves toward the DNP as the preferred educational pathway for APRN preparation (American Association of Colleges of Nursing [AACN], 2006). Another significant implication of the Dreyfus model (Dreyfus & Dreyfus, 1986, 2009) for APRNs is the observation that the quality of performance may deteriorate when performers are subjected to intense scrutiny, whether their own or that of someone else (Roberts, Tabloski, & Bova, 1997). The increased anxiety experienced by APRN students during faculty on-site clinical evaluation visits or during videotaped testing of clinical performance in simulated situations is an example of responding to such intense scrutiny. A third implication of this skill acquisition model for APRNs is the need to accrue experience in actual situations over time, so that practical and theoretical knowledge are refined, clarified, personalized, and embodied, forming an individualized repertoire of experience that guides advanced practice performance. As the profession encourages new nurses to move more rapidly into APRN education, students, faculty, and educational programs must search for creative ways to incorporate the practical and theoretical knowledge necessary for advanced practice nursing. Discussing unfolding cases is a useful approach for teaching the clinical reasoning in transition that is so essential for clinical practice (Benner et al., 2010; Day, Cooper, & Scott, 2012). Role Concepts and Role Development Issues This discussion of professional role issues incorporates role concepts described by Hardy and Hardy (1988) and Schumacher and Meleis (1994), along with the concept that different APRN roles represent different subcultural groups within the broader nursing culture (Leininger, 1994). Building on Johnson's (1993) conclusion that NPs have three voices, Brykczynski (1999a) described APRNs as tricultural and trilingual. They share background knowledge, practices, and skills of three cultures—biomedicine, mainstream nursing, and everyday life. They are fluent in the languages of biomedical science, nursing knowledge and skill, and everyday parlance. Some APRNs (e.g., CNMs) are socialized into a fourth culture as well, that of midwifery. Others are also fluent in more than one everyday language. The concepts of role stress and strain discussed by Hardy and Hardy (1988) are useful for understanding the dynamics of role transitions (Table 4.1). Hardy and Hardy described role stress as a social structural condition in which role obligations are ambiguous, conflicting, incongruous, excessive, or unpredictable. Role strain is defined as the subjective feeling of frustration, tension, or anxiety experienced in response to role stress. The highly stressful nature of the nursing profession needs to be recognized as the background within which individuals seek advanced education to become APRNs (Aiken, Clarke, Sloan, Sochalski, & Silber, 2002; Dionne-Proulz & Pepin, 1993). Role strain can be minimized by the identification of potential role stressors, development of coping strategies, and rehearsal of situations designed for application of those strategies. However, the difficulties experienced by neophytes in new positions cannot be eliminated. As noted, expertise is holistic, involving embodied perceptual skills (e.g., detecting qualitative distinctions in pulses or types of anxiety); formation of character, identity, and ethical judgment; shared background knowledge; and cognitive ability. A school-work, theory-practice, ideal-real gap will remain because of the nature of human skill acquisition, which occurs over time, and the undetermined nature of situations in actual practice, which requires engaged situated reasoning and consideration of patient preferences, practice standards, costs, clinical outcomes, and numerous other aspects that vary with each situation. TABLE 4.1 Selected Role Concepts Concept Definition Examples Role stress A situation of increased role performance demand Role strain Subjective feeling of frustration, tension, or anxiety in response to role stress Feeling of decreased self-esteem when performance is below expectations of self or significant others. Role stressors Factors that produce role stress Financial, personal, or academic demands and role expectations that are ambiguous, conflicting, excessive, or unpredictable. Role ambiguity Unclear expectations, diffuse responsibilities, uncertainty about subroles Recent graduates' uncertainty about role expectations. Some degree of ambiguity exists in all professional positions because of the evolving nature of roles and expansion of skills and knowledge. Role incongruity A role with incompatibility between skills and abilities and role obligations or between personal values and self-concept and role obligations An adult nurse practitioner in a role requiring pediatric skills and knowledge. Difficulty of incorporating holistic nursing aspects of care into medical model. Role conflict Occurs when role expectations are perceived to be mutually exclusive or contradictory Role transition A dynamic process of change over time as new roles are acquired Returning to school while maintaining work and family responsibilities. The expectation of increased workload (number of patients seen). Keeping up with rapidly changing technology. Coping with restrictions related to payment system limitations. Role conflict between advanced practice registered nurses (APRNs) and other nurses and between APRNs and physicians. Changing from a staff nurse to an APRN role. Advancing from a master's-prepared APRN to a Doctor of Nursing Practice–prepared APRN. Role insufficiency Feeling inadequate to meet role demands Role Anticipatory socialization supplementation New APRN graduates experiencing feelings of inadequacy as a result of increased workload expectations and electronic health records documentation requirements. Change from solo practice or clinic to hospital requirements through mergers and acquisitions. Role-specific educational components in a graduate program (e.g., interviewing a practicing APRN or a clinical preceptorship experience with an APRN). Adapted from Hardy, M. E., & Hardy, W. L. (1988). Role stress and role strain. In M. E. Hardy & M. E. Conway (Eds.), Role theory: Perspectives for health professionals (2nd ed., pp. 159– 239). Norwalk, CT: Appleton & Lange; and Schumacher, K. L., & Meleis, A. I. (1994). Transitions: A central concept in nursing. Image: The Journal of Nursing Scholarship, 26, 119–127. Bandura's (1977) social cognitive theory of self-efficacy may be of interest to APRNs in terms of understanding what motivates individuals to acquire skills and what builds confidence as skills are developed. Self-efficacy theory—a person's belief in his or her ability to succeed—has been used widely to further understanding of skill acquisition with patients (Burglehaus, 1997; Clark & Dodge, 1999; Dalton & Blau, 1996). Self-efficacy theory has also been applied to mentoring APRN students (Hayes, 2001) and training health care professionals in skill acquisition (Parle, Maguire, & Heaven, 1997). Attention to varied learning styles, different neurocognitive processes involved in learning, and APRN students as adult learners is important for teaching (Burns, Beauchesne, Ryan-Krause, & Sawin, 2006; Kumar, Fathima, & Mohan, 2013). Role Ambiguity Role ambiguity (see Table 4.1) develops when there is a lack of clarity about expectations, a blurring of responsibilities, uncertainty regarding role implementation, and the inherent uncertainty of existent knowledge. According to Hardy and Hardy (1988), role ambiguity characterizes all professional positions. They have noted that role ambiguity might be positive in that it offers opportunities for creative possibilities. It can be expected to be more prominent in professions undergoing change, such as those in the health care field. To avoid uncertainty about roles in interprofessional educational experiences and promote successful interprofessional practice, a focus on the following key components is important: awareness of one's own professional role, understanding the professional roles of others, leadership skills, principles of teamwork, and conflict negotiations skills and knowledge (MacDonald et al., 2010). Role ambiguity has been widely discussed in relation to the CNS role (Bryant-Lukosius et al., 2010; Hamric, 2003; see also Chapter 14), but it is also a relevant issue for other APRN roles (Kelly & Mathews, 2001), particularly as APRN roles evolve (Stahl & Myers, 2002). Role Incongruity Role incongruity is intrarole conflict, which Hardy and Hardy (1988) described as developing from two sources. Incompatibility between skills and abilities and role obligations is one source of role incongruity. An example of this is an adult APRN hired to work in an emergency department with a large percentage of pediatric patients. Such an APRN will find it necessary to enroll in a family NP or pediatric NP program to gain the knowledge necessary to eliminate this role incongruity. This is a growing issue as NP roles become more specialized. Another source of role incongruity is incompatibility among personal values, self-concept, and expected role behaviors. An APRN interested primarily in clinical practice may experience this incongruity if the position that she or he obtains requires performing administrative functions. An example comes from Banda's (1985) study of psychiatric liaison CNSs in acute care hospitals and community health agencies. She reported that they viewed consultation and teaching as their major functions, whereas research and administrative activities produced role incongruity. Role Conflict Role conflict develops when role expectations are perceived to be contradictory or mutually exclusive. APRNs may experience conflict with varying demands of their role as well as intraprofessional and interprofessional role conflict. Intraprofessional Role Conflict APRNs experience intraprofessional role conflict for a variety of reasons. The historical development of APRN roles has been fraught with conflict and controversy in nursing education and nursing organizations, particularly for CNMs (Varney, 1987), NPs (Ford, 1982), and CRNAs (Gunn, 1991; see also Chapter 1). Relationships among these APRN groups and nursing as a discipline have improved markedly in recent years, but difficulties remain (Fawcett, Newman, & McAllister, 2004). The degree to which APRN roles demonstrate a holistic nursing orientation as opposed to a more disease-specific medical orientation remains problematic (see additional discussion under Interprofessional Role Conflict, later). Communication difficulties that underlie intraprofessional role conflict occur in four major areas: (1) at an organizational level, (2) in educational programs, (3) in the literature, and (4) in direct clinical practice. Kimbro (1978) initially described these communication difficulties in reference to CNMs, but they are relevant for all APRN roles. The fact that CNSs, NPs, CNMs, and CRNAs each have specific organizations with different certification requirements, competencies, and curricula creates boundaries and sets up the need for formal lines of communication. Communication gaps occur in education when courses and textbooks are not shared among APRN programs, even when more than one specialty is offered in the same school. Specialtyspecific journals are another formal communication barrier because APRNs may read primarily within their own specialty and not keep abreast of larger APRN issues. In clinical settings, some APRNs may be more concerned with providing direct clinical care to individual patients, whereas staff nurses and other APRNs may be more concerned with 24-hour coverage and smooth functioning of the unit or institution. These differences may set the stage for intraprofessional role conflict. During the 1980s and 1990s, when there was more confusion about the delineation of roles and responsibilities between RNs and NPs, RNs would sometimes demonstrate resistance to NPs by refusing to take vital signs, obtain blood samples, or perform other support functions for patients of NPs (Brykczynski, 1999b; Hupcey, 1993; Lurie, 1981), and they were not admonished by their supervisors for these negative behaviors. These behaviors are suggestive of horizontal violence (a form of hostility), which may be more common during nursing shortages (Thomas, 2003). Roberts (1983) first described horizontal violence among nurses as oppressed group behavior wherein nurses who were doubly oppressed as women and as nurses demonstrated hostility toward their own less powerful group, instead of toward the more powerful oppressors. Recognizing that intraprofessional conflict among nurses is similar to oppressed group behavior can be useful in the development of strategies to overcome these difficulties (Bartholomew, 2006; Brykczynski, 1997; Farrell, 2001; Freshwater, 2000; Roberts, 1996; Rounds, 1997). According to Rounds (1997), horizontal violence is less common among NPs as a group than among RNs generally. Over the years, as the NP role has become more accepted by nurses, there appear to be fewer cases of these hostile passive-aggressive behaviors, often currently referred to as bullying, toward NPs. However, they have been reported in APRN transition literature (Heitz et al., 2004; Kelly & Mathews, 2001). Heath (2014) identified courage as a key factor to address bullying, including “courage to stand up to a bully in a nonthreatening manner and courage to speak up if bullying is witnessed or experienced” (p. 441). One way to address these issues would be to include APRN position descriptions in staff nurse orientation programs. Curry claimed (1994) that thorough orientation of staff nurses to the APRN role, including clear guidelines and policies regarding responsibility issues, is an important component of successful integration of NP practice in an emergency department setting; this is also applicable to other roles and settings. Another significant strategy for minimizing intraprofessional role conflict is for the new APRN, and APRN students, to spend time getting to know the nursing staff to establish rapport and learn as much as possible about the new setting from those who really know what is going on—the nurses. This action affirms the value and significance of nurses and nursing and sets up a positive atmosphere for collegiality and intraprofessional role cooperation and collaboration. In Kelly and Mathews' study (2001) of new NP graduates, such a strategy was exactly what new NPs regretted not having incorporated into their first positions. Interprofessional Role Conflict Conflicts between physicians and APRNs constitute the most common situations of interprofessional conflict. Major sources of conflict for physicians and APRNs are the perceived economic threat of competition, limited resources in clinical training sites, lack of experience working together, and the historical hierarchy. The relationship between anesthesiologists and CRNAs is an exemplar of ongoing conflict and clearly depicts interprofessional role conflict between physicians and APRNs (Exemplar 4.1). Exemplar 4.1 Interprofessional Role Conflict: The Case of Certified Registered Nurse Anesthetists and Anesthesiologists For many years, nurse anesthetists have provided high-quality anesthesia care in a variety of settings. They are the primary anesthesia providers in rural US hospitals, as noted on the American Association of Nurse Anesthetists (AANA) website (www.aana.com). According to the AANA (2016), more than 49,000 certified registered nurse anesthetists (CRNAs) provide quality anesthesia care to more than 65% of all patients undergoing surgical or other medical interventions that necessitate the services of an anesthetist (see Chapter 18). The fact that nurse anesthetists predated the first physician anesthesiologists by many years (see Chapter 1) may partly explain why the relationship between anesthesiologists and CRNAs has historically been interpreted by anesthesiologists as one of direct competition, thus creating an adversarial stance. Over the years, this relationship might be characterized as a cold war with overt offensives mounted periodically by anesthesiologists. In 1970, CRNAs outnumbered anesthesiologists by a ratio of 1.5 : 1. By 2000, anesthesiologists outnumbered CRNAs (Blumenreich, 2000). Currently there are equal numbers of CRNAs and anesthesiologists; however, an anesthesiologist shortage and a surplus of CRNAs is predicted by 2020 (Conover, 2015; Jordan, 2011). This is one of the factors underlying conflicts over CRNA autonomy (see the AANA website, www.aana.com, for updates on this issue). Another factor is the decision made by the Centers for Medicare and Medicaid Services, after study of the available evidence in 1997, to reimburse nurse anesthetists directly under Medicare (Kleinpell, 2001). In response, anesthesiologists and the American Medical Association launched a major campaign against CRNA autonomy in the operating room, claiming that supervision of CRNAs by physicians is essential for public safety (Federwisch, 1999; Kleinpell, 2001; Stein, 2000; see also Chapter 18). Despite the very active political action committee of the American Nurses Association, the struggle with physicians over limiting the scope of practice of CRNAs is ongoing and reflects the experiences of other advanced practice nurse groups as well. An example of this continuing struggle is the Scope of Practice Partnership (SOPP), a coalition formed by the American Medical Association with other physician organizations to mount initiatives to limit the scope of practice of nonphysician clinicians (Waters, 2007). SOPP funds investigations into the educational preparation and licensure requirements of health care providers with the goal of opposing autonomous practice. SOPP targets all nonphysician providers (Lindeke & Thomas, 2010). A current issue of role delineation and conflict is the anesthesiologists' efforts to categorize CRNAs and anesthesiologist assistants (AAs) on the same level as mid-level clinicians. Both are nonphysician anesthetists; however, the fundamental difference is that an AA works under the direct supervision of the physician and is trained using the medical model of education. The relationship between nonphysician anesthesia providers mimics the adversarial relationship that previously existed between physician assistants and nurse practitioners. Collegial relationships among the nonphysician providers may be more beneficial for both groups. The American Academy of Anesthesiologist Assistants (2016) website identifies 10 accredited programs for AAs in the United States, and 1800 practicing AAs. There are 114 accredited CRNA programs and approximately 40,000 practicing CRNAs (AANA, 2016). CRNAs are currently educated at the Master's of Science in Nursing level; however, this is changing. By 2025, all CRNAs will be required to have a doctorate for entry into practice (AANA, 2007). Thus the CRNA is achieving what nursing has been struggling with for the past few decades. The quality of care and patient safety provided by the CRNA has been well documented in peer-reviewed journals (AANA, 2016). Physicians still continue to verbalize the need for supervision, quoting patient safety and ignoring the evidence. Role acceptance is an ongoing issue for all advanced practice registered nurses. Progress is being made, but active participation and a strong voice are still needed to bring about the much-needed change. One way to promote positive interprofessional relationships is to provide education and practice experiences that include APRN students, medical students, and both physician and APRN faculty to enhance mutual understanding of both professional roles (Kelly & Mathews, 2001). Developing such interprofessional educational experiences is difficult because of different academic calendars and clinical schedules. However, these obstacles can be overcome if these interdisciplinary activities are considered essential for improved health care delivery and if they have sufficient administrative support (Wynia, Von Kohorn, & Mitchell, 2012). The issues of professional territoriality and physician concern about being replaced by advanced practice nurses were reported by Lindblad, Hallman, Gillsjö, Lindblad, and Fagerström (2010) from an ethnographic study of the first four graduates in 2005 from the first CNS program in Sweden. The CNSs and general practitioners agreed that the usefulness of the CNSs would have been greater if they had been able to prescribe medications and order treatments. After working with the CNSs, the general practitioners saw them more as an additional resource and complement rather than a threat. By 2009, there were 16 CNSs working in the new role in primary health care. The numbers of advanced practice nurses have increased gradually in Sweden. A study by Altersved, Zetterlund, Lindblad, and Fagerström (2011) indicates that the CNS is recognized as a resource to increase accessibility to more holistic primary care; however, the barriers of limited autonomy and lack of prescriptive authority need to be addressed to further role development. The complementary nature of advanced practice nursing to medical care is a foreign concept for some physicians, who view all health care as an extension of medical care and see APRNs simply as physician extenders. This misunderstanding of advanced practice nursing underlies physicians' opposition to independent roles for nurses because they believe that APRNs want to practice medicine without a license (see Chapters 1 and 3). In fact, numerous earlier studies of APRN practice have demonstrated that advanced practice roles incorporate a holistic approach that blends elements of nursing and medicine (Brown, 1992; Brykczynski, 1999a, 1999b; Fiandt, 2002; Grando, 1998; Johnson, 1993). However, when APRNs are viewed by physicians as direct competitors, it is understandable that some physicians would be reluctant to be involved in assisting with APRN education (National Commission on Nurse Anesthesia Education, 1990). In addition, some nurse educators have believed that physicians should not be involved in teaching or acting as preceptors for APRNs. Improved relationships between APRNs and physicians will require redefinition of the situation by both groups. The advocacy of the Interprofessional Education Collaborative Expert Panel (2011) for an interprofessional vision for all health professionals and the recommendation by the Institute of Medicine (2003) that the health professional workforce be prepared to work in interdisciplinary teams underscore the imperative of interprofessional collaboration (see Chapter 12). Competency in interprofessional collaboration is critical for APRNs because it is central to APRN practice (Farrell, Payne, & Heye, 2015). This content is incorporated into the leadership and interprofessional partnership components of The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). Some interesting research has emerged on this issue in Canada and Europe. A participatory action research study conducted in British Columbia, Canada, indicated that NPs viewed collaboration as both a philosophy and a practice: “They cultivated collaborative relations with clients, colleagues, and health care leaders to address concerns of role autonomy and role clarity, extend holistic clientcentered care and team capacity, and create strategic alliances to promote innovation and system change” (Burgess & Purkis, 2010, p. 300). Of particular importance is the fact that the NP participants described themselves as being nurses first and practitioners second. This is significant because when role emphasis is on physician replacement and support rather than on the patient-centered, healthfocused, holistic nursing orientation to practice, the nursing components of the role become less valued and invisible (BryantLukosius, DiCenso, Browne, & Pinelli, 2004). Medically driven and illness-oriented health systems tend to devalue these value-added components of APRN roles, and reimbursement mechanisms for including these aspects of care are lacking. Fleming and Carberry (2011) reported on a grounded theory study of expert critical care nurses transitioning to advanced practice in an intensive care unit setting in Scotland. Initial perceptions were that the advanced practice nursing role was closely aligned with medical practice, but later perceptions supported earlier studies that the advanced practice nursing role was characterized by an integrated, holistic, patient-centered approach to care, which was close to the medical model but different because it was carried out within an expert nursing knowledge base. The authors determined that further research is needed to explore the outcomes of this integrated practice. This is the research imperative for advanced practice nursing—to demonstrate the impact of the holistic nursing approach to care on patient outcomes. Nurse-midwives have been in the forefront of developing collaborative relationships with physicians for many years. All APRN groups would benefit from attention to the progress that CNMs have made in collaboration with physicians. The joint practice statement of the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (2011) can be used as a model for other APRN groups. It highlights key principles for improving communication, working relationships, and seamlessness in the provision of women's health services (see also the American College of Nurse-Midwives website, www.acnm.org). Problems with previous joint practice statements were that they included varying interpretations of physician supervision. The Executive Summary of the Task Force for Collaboration in Practice and Implementing Teambased Care released by the ACOG in 2016 defines team-based care as involving at least two health care providers working collaboratively with patients as full participants, with health care providers functioning to the full extent of their education, certification, and experience (ACOG, 2016). Role Transitions Role transitions are defined here as dynamic processes of change that occur over time as new roles are acquired (see Table 4.1). The middlerange transitions theory of Meleis, Sawyer, Im, Hilfinger-Messias, and Schumacher (2000) has been widely used in both undergraduate and graduate education. It can be helpful for understanding and addressing the situational transitions associated with APRN role development. Five essential factors influence role transitions (Schumacher & Meleis, 1994): (1) personal meaning of the transition, which relates to the degree of identity crisis experienced; (2) degree of planning, which involves the time and energy devoted to anticipating the change; (3) environmental barriers and supports, which refer to family, peer, school, and other components; (4) level of knowledge and skill, which relates to prior experience and school experiences; and (5) expectations, which are related to such factors as role models, literature, and media. The role strain experienced by individuals in response to role insufficiency (see Table 4.1 for definitions) that accompanies the transition to APRN roles can be minimized, although certainly not completely prevented, by individualized assessment of these five essential factors, development of strategies to cope with them, and rehearsal of situations designed for application of these strategies. Entering graduate school may be associated with a ripple effect of concurrent role transitions in family, work, and other social arenas (Klaich, 1990). Advanced Practice Nurse Role Acquisition in Graduate School The personal meaning of role transitions has been a major focus of APRN role development literature over the years, with alterations in self-identity and self-concept emerging as a consistent theme and role acquisition experiences sometimes described as identity crises (Roberts, Tabloski, & Bova, 1997). Studies of APRN role acquisition in school are outlined in Table 4.2. TABLE 4.2 a Studies are listed in chronological order. FNP, Family nurse practitioner; MSN, Master's of Science in Nursing; NP, nurse practitioner. In their study of NP students, Roberts et al. (1997) reported findings similar to those observed decades earlier by Anderson, Leonard, and Yates (1974). The description by Anderson et al. (1974) of NP students' progression from dependence to interdependence being accompanied by regression, anxiety, and conflict was found to be similar to observations made by Roberts et al. (1997) in graduate NP students over a period of 6 years (see Table 4.2). For many years, we (the authors) and our NP faculty colleagues have observed similar role transition processes in teaching role and clinical courses for graduate NP students. In a discussion of role transition experiences for neonatal NPs (NNPs), Cusson and Viggiano (2002) made the important point that even positive transitions are stressful. Roberts et al. (1997) identified three major areas of transition as students progressed from dependence to interdependence: (1) development of professional competence, (2) change in role identity, and (3) evolving relationships with preceptors and faculty. The lowest level of competence coincided with the highest level of role confusion. This occurred at the end of the first semester and the beginning of the second semester in the three-semester program examined. Roberts et al. observed that the most intense transition period typically occurred at the end of the students' first clinical immersion experience. Roberts et al. (1997) described the first transition as involving an initial feeling of loss of confidence and competence accompanied by anxiety. Initial clinical experiences were associated with the desire to observe rather than provide care, the inability to recall simple facts, the omission of essential data from history taking, feelings of awkwardness with patients, and difficulty prioritizing data. The students' focus at this time was almost exclusively on acquiring and refining assessment skills and continued development of physical examination techniques. By the end of the first semester, students reported returning feelings of confidence and the regaining of their former competence in interpersonal skills. Although they were still tentative about diagnostic and treatment decisions, students reported feeling more comfortable with patients as some of their basic nursing abilities began to return. Transitions in nursing role identity occurring during the first two stages were associated with feelings of role confusion. Students were dismayed at how slowly and inefficiently they were performing in clinical situations and reported feelings of self-doubt and lack of confidence in their abilities to function in the real world of health care. They sought shortcuts in attempts to increase their efficiency. They reported profound feelings of responsibility regarding diagnostic and treatment decisions and, at the same time, increasingly realized the limitations of clinical practice when they were confronted with the real-life situations of their patients. They recalled finding it easy to second-guess physicians' decisions in their previous nursing roles, but now they found those decisions more problematic when they were responsible for making them. They joked about feeling like adolescents. This is the point that Cusson and Viggiano (2002) were making when they commented, in reference to NNPs, that the infant really does look different when viewed from the head of the bed rather than the side of the bed. They explained that “rather than taking orders, as they did as staff nurses, neonatal NPs must synthesize incredibly complex information and decide on a plan of action. Experienced neonatal nurses often guide house staff regarding care decisions and writing orders to match the care that is being given. However, the shift in responsibility to actually writing the orders can be very intimidating” (p. 24). Roberts et al. (1997) observed that a blending of the APRN student and the former nurse developed during stage II of the transition process as students renewed their appreciation for their previous interpersonal skills as teachers, supporters, and collaborators and again perceived their patients as unique individuals in the context of their life situations. Students developed increased awareness of the uncertainty involved in the process of making definitive diagnostic and treatment decisions. In spite of current attempts to reduce diagnostic and treatment uncertainty through evidence-based practice, a basic degree of uncertainty is still inherent in clinical practice. Although these insights served to demystify the clinical diagnostic process, the students' anxiety about providing care increased. Learning about strategies to cope with clinical decision making in situations of uncertainty, such as ruling out the worst case scenario, seeking consultation, and monitoring patients closely with phone calls and follow-up visits, can decrease anxiety and promote increased confidence (Brykczynski, 1991). The transition in the relationships between students and preceptors and students and faculty in the study by Roberts et al. (1997) involved students feeling anxious that they were not learning enough and would never know enough to practice competently. Students felt frustrated and perceived that faculty and preceptors were not providing them with all the information they needed. During the third stage, as they felt more confident and competent, students began to question the clinical judgments of their preceptors and faculty. This process is thought to help students advance from independence to interdependence—the last stage of the transition process. Much of the conflict at this juncture appeared to derive from students' feelings of “ambivalence about giving up dependence on external authorities” (Roberts et al., 1997, p. 71) such as preceptors and faculty and assuming responsibility for making independent judgments based on their own assessments from their clinical and educational experiences and the literature. The relevance of these role acquisition processes for other APRN roles has not been reported. This is an area in which research would be helpful. Fleming and Carberry's (2011) qualitative study of critical care nurse advanced practice trainees in Scotland provides confirmation of the experiences described here. They noted the trainees' feelings of inadequacy associated with moving from expert to novice and their anxiety and frustration over dealing with the role ambiguity of moving into a hybrid nursing and medical role. After a 12-month period, the trainees found their role “characterized by an integrated holistic patient-centered approach to care” (p. 74). Until recently, the literature on APRN role acquisition in school has focused exclusively on individuals who were already nurses. A commonly held assumption among nurses is “the more clinical experience, the better” for acquiring the necessary knowledge and skill to take on complex APRN roles. At least 1 year of nursing practice is typically preferred for admission to APRN programs. The process of role acquisition for students in direct-entry APRN master's programs that admit non-nurse college graduates may differ because these individuals were not functioning as nurses before they entered the program. For additional information regarding this topic, the reader is referred to the qualitative study reported by Rich and Rodriguez (2002). In their qualitative study of family nurse practitioner (FNP) role transition, Heitz et al. (2004) found differences in role acquisition experiences between FNP students who were inexperienced nurses and FNP students who were experienced nurses. Feelings of insecurity, inadequacy, vulnerability, and being overwhelmed were typical, but role confusion was reported primarily by the more experienced RN students as they went through the process of letting go of the RN role and taking on the FNP role. It will be interesting to observe whether this finding holds true for students transitioning from the Bachelor of Science in Nursing to the DNP. Strategies to Facilitate Role Acquisition The anticipatory socialization to APRN roles that occurs in graduate education is analogous to a process that Kramer (1974) described for undergraduate RNs called “immunization.” This same process is referred to as role supplementation in transitions theory (Schumacher & Meleis, 1994). The overall objective is to expose students to as many real-life experiences as possible during the educational program to minimize reality shock and role insufficiency on graduation and initial role implementation. Role content can be incorporated into APRN curricula in a variety of ways, including: (1) in the overall framework for designing an APRN curriculum; (2) in a specific role course (see, e.g., Spoelstra & Robbins, 2010); (3) as part of specific assignments; and (4) in role seminars that span an entire curriculum. Hamric and Hanson (2003) asserted that it is an ethical mandate for all APRN educators, regardless of specialty, to provide graduates with up-todate knowledge of professional role and regulatory issues in addition to concentration on clinical competence. The importance of explicit role preparation for the complex and challenging roles of graduates of DNP programs is recognized in the curriculum proposed by the AACN (2006). If there is not a separate role course, careful attention must be paid to this curriculum component so that it does not become integrated out of existence. Specific strategies for facilitating role acquisition can be categorized according to three major purposes: (1) role rehearsal; (2) development of clinical knowledge and skills, including strategies for dealing with uncertainty; and (3) creation of a supportive network (Table 4.3). Rites of passage can be useful for signifying advancement to a new level of practice and set the stage for role rehearsal. The Willow Ceremony is a rite of passage developed at the University of Wyoming to commemorate beginning an APRN program (Burman, Hart, Conley, Caldwell, & Johnson, 2007). For adequate role rehearsal, APRN students should experience all aspects of the core competencies (see Chapter 3) directly while faculty and fellow students are available to help them process or debrief these experiences. Faculty can help students by identifying role acquisition periods of high stress in their particular program so that support can be built in during those periods. APRN students should be cautioned that other nurses, physicians, other providers, and administrators in the work setting may value only clinical expertise and not the other core competencies. Strategies for enhancing understanding of how the core competencies are embedded in each APRN role include preparation of short-term and long-term goals to use as guides in the development of professional portfolios, analysis of existing position descriptions, and development of the ideal position description. These are also helpful for guiding students in their search for an initial APRN position. TABLE 4.3 Adapted from Brykczynski, K. A. (2000). Chart 1-6: Strategies to promote NP role acquisition in school. In P. Meredith & N. M. Horan (Eds.), Adult primary care (p. 16). Philadelphia: WB Saunders. Clinical Knowledge Development The development of clinical knowledge and skills for APRN role acquisition can be promoted by planning for realistic clinical experiences with the support of faculty and preceptors nearby. Steiner, McLaughlin, Hyde, Brown, and Burman (2008) pointed out the importance of teaching students how to learn and how to use resources to find out what they need to know. Emphasis on realism and a holistic situational perspective are important in clinical experiences for helping students understand that the complex clinical judgments involved in APRN assessment and management of patient situations over time are not simply technical medical knowledge but a hybrid of nursing and medical knowledge and experience. Teaching and learning experiences for all the APRN role components should integrate elements of research and theory and be incorporated into specialty APRN courses to build on the knowledge gained in the traditional graduate core and clinical support courses in the curriculum. New APRN graduates can benefit from familiarity with role transition processes by not expecting to be able to demonstrate all APRN role components fully and expertly immediately on graduation. Clinical mentoring by preceptors is an important component of ensuring realistic clinical learning experiences and socialization into advanced practice nursing roles (AACN, 2015b; Burns et al., 2006; Donley et al., 2014). APRN student enrollment has increased markedly in the face of APRN faculty shortages, and APRN students enter clinical training experiences across the curriculum with varied skill levels (AACN, 2015). Identifying qualified and available preceptors is challenging and time consuming for faculty and support staff (Multidiscipline Clerkship/Clinical Training Site Survey, 2014). Students are matched with qualified APRN and non-nurse preceptors to provide learning opportunities, ensure development of required clinical skills, and foster the team concept. Course objectives, the advanced practice essentials (whether master's or doctoral), core competencies for the specific APRN role, and a preceptor learning agreement provide the basic structure and overall direction for faculty, preceptors, and students. Clinical faculty are responsible for conducting site visits and convening clinical conferences to evaluate learning. APRN course faculty are responsible for student, clinical faculty, preceptor, and clinical site evaluation and overall maintenance of high-quality educational standards. APRN students are linked with preceptors for one-on-one guidance in developing clinical skills and judgment. This apprenticeship model of education is time intensive and costly (AACN, 2015b). All of these challenges require APRN educational programs to explore new and alternative models for providing clinical training, including increased use of low- and high-fidelity simulation to support clinical experiences and to evaluate students, and increased attention to interprofessional practice (AACN, 2015b). In 2012, the Centers for Medicare and Medicaid Services (CMS) launched the Graduate Nurse Education Demonstration project to increase the numbers of primary care NPs in an effort to address the increasing need for access to primary care providers (CMS, 2012). The CMS provided reimbursement for eligible hospitals to participate in the demonstration project in five major cities (Hospital of the University of Pennsylvania, Philadelphia, PA; Duke University Hospital, Durham, NC; Scottsdale Healthcare Medical Center, Scottsdale, AZ; Rush University Medical Center, Chicago, IL; and Memorial Hermann-Texas Medical Center Hospital, Houston, TX). The hospitals partnered with accredited advanced practice nursing programs and reimbursed preceptors for training NP students (American Association of Nurse Practitioners [AANP], 2012). Project funding had already started decreasing by 2016, and a current concern is that preceptors may now expect reimbursement (CMS, 2015). Incentivizing community preceptors with educational opportunities, documentation of preceptor hours for recertification, and library access may motivate participation in the student-preceptor collaborative relationship (AACN, 2015b; Donley et al., 2014). Collaboration between schools of nursing and health care agencies in developing more formal systems of rewards and benefits that facilitate professional development and career mobility for preceptors is imperative for enhancing their recruitment and retention (AACN, 2015a; Donley et al., 2014). Anticipatory planning for the first APRN position after program completion is important. In the current cost-constrained environment, the pressure to be cost-effective and to make an impact on health outcomes is greater than ever, but studies have shown that the initial year of practice is one of transition (Brown & Olshansky, 1998; Kelly & Mathews, 2001) and that an APRN's maximum potential may not be realized until after approximately 5 or more years in practice (Cooper & Sparacino, 1990). Reports of the transition experiences of new NP graduates during their first year after graduation suggest that the first position can be critical in terms of solidifying the NP's career (Brown & Olshansky, 1997; Heitz et al., 2004; Kelly & Mathews, 2001; Steiner et al., 2008). Preparation of students for assuming APRN roles on graduation should be a collaborative effort of students, faculty, and preceptors. The need for position descriptions that clearly outline roles and responsibilities has been emphasized as essential for smooth role transition (Cooper & Sparacino, 1990; Hamric & Taylor, 1989; McMyler & Miller, 1997). The transition to the first position is a process, not an event, that may take 6 months to 2 years (Steiner et al., 2008). It needs to be a focus of role content in APRN programs (Hamric & Hanson, 2003; Hunter, Bormann, & Lops, 1996). Finally, and perhaps most importantly, an overall strategy for enhancing APRN clinical knowledge and skill is for faculty to maintain competency in clinical practice. Clinical competency enhances the faculty's ability to evaluate students clinically, discuss clinically relevant examples in classes, serve as preceptors for students, and evaluate the care provided in clinical preceptorship sites. The clinical competence of faculty is important to prevent a wide gap between education and practice, enhance faculty credibility, and foster realistic expectations for new APRN graduates. Developing a Supportive Network Establishing a peer support system, planning social functions with faculty and preceptors, and creating a virtual community can facilitate the development of a support network. The importance of forming a support network was emphasized by study findings (Kelly & Mathews, 2001; Kleinpell-Nowell, 2001). Computer literacy is critical for networking and access to the high-quality materials available on websites, in literature searches, and on smartphones. Students need expanded informatics skills and understanding of emerging technologies, including genetics and genomics, less invasive diagnostic tools and treatments, three-dimensional printing, robotics, biometrics, electronic health records, computerized provider order entry, and clinical decision support, to enhance their ability to practice (Huston, 2013). Neurocognitive theory provides evidence-based approaches to improving learning incorporating a wide variety of multimedia tools. Instructional design has added visual comprehension through videos, simulation, and interactive programs (Anderson, Love, & Tsai, 2014). The establishment of a system for self-directed learning activities during the first few years after program completion forms the basis for maintaining competence throughout one's career (Gunn, 1998). The formation of a process for lifelong learning should be initiated during the APRN educational program as students create a computerbased, self-monitoring system that includes clinical and role transition experiences over time to serve as a reality check or timetable. On graduation, continuing education program attendance could be incorporated into this monitoring system to facilitate compilation of necessary documentation for certification, along with ongoing selfevaluation and role development. This information can be incorporated into students' online portfolios to centralize all career materials in one place. Students need to be encouraged to develop and maintain self-care practices during their stressful educational experiences that they can continue when they move into the challenges of the practice arena. Faculty can serve as role models for healthy lifestyles and incorporate analysis of self-care practices into assignments to aid students in developing improved well-being. Students invariably develop renewed appreciation from these self-care assignments for how difficult it is to change health habits, and they can share knowledge they gain from these learning experiences with peers and patients. Advanced Practice Nursing Role Implementation at Work After successfully emerging from the APRN educational process, new APRN graduates face yet another transition, from the student role to the professional APRN role, referred to as role implementation in this text (see Fig. 4.1). APRN graduates can be expected to experience attitudinal, behavioral, and value conflicts as they move from the academic world, in which holistic care is highly valued, to the work world, in which organizational efficiency is paramount. Anticipatory guidance is needed for role transition yet again. The process of APRN role implementation is another situational transition (Schumacher & Meleis, 1994) that is described here as a progressive movement through three or four phases or stages. In the APRN role development literature the term phase is used by some and the term stage is used by others (Poronsky, 2013). After checking several dictionaries, it is clear that the terms are synonymous and can be used interchangeably. One term is often favored over another in different fields; for example, in pharmacology drug trials are referred to in different phases whereas in human development the term stage is preferred. For the discussion here, the terms phase and stage are used as cited in the different studies (Table 4.4). TABLE 4.4 a Studies are listed in chronological order. CNSs, Clinical nurse specialists; DSNs, diabetes specialist nurses; FNP, family nurse practitioner; MSN, Master's of Science in Nursing; NNP, neonatal nurse practitioner; NP, nurse practitioner. Hamric and Taylor (1989) described seven phases of CNS role development (see Table 4.4). There is general agreement that significant overlap and fluidity exist among the phases; however, for purposes of discussion they are considered sequentially. Of 42 CNSs in their first positions for 3 years or less, 40 experienced progression through the first three phases (identical to the first three phases identified by Baker [1979]). Most of the CNS respondents went through these three phases within 2 years. Phase 1, the orientation phase, is characterized by enthusiasm, optimism, and attention to mastery of clinical skills. Phase 2, the frustration phase, is associated with feelings of conflict, inadequacy, frustration, and anxiety. Arena and Page (1992) identified the imposter phenomenon as a feature of CNS practice that could interfere with effective role implementation. In retrospect, it appears that the imposter phenomenon is one of the distressing features of the frustration phase. Phase 3, implementation, involves role modification in response to interactions with others and development of more realistic perspective as role expectations are adjusted. CNSs with more than 3 years of experience described their role development experiences in terms very different from Baker's (1979) phases. Content analysis of these data led to a description of four additional phases (see Table 4.4). Experienced CNSs identified the integration phase, which was characterized by “self-confidence and assurance in the role, high job satisfaction, an advanced level of practice, and signs of recognition and respect for expertise within and outside the work setting” (Hamric & Taylor, 1989, p. 56). Only 10% of the CNSs with less than 5 years of experience in the role met the criteria for this phase, whereas 50% of those with more than 6 years of experience could be categorized as being in this phase. The integration phase was typically reached after 3 to 5 years in the CNS role. This fourth phase of integration—thought to be reached only after successful transition through the earlier phases—is characterized by refinement of clinical expertise and integration of role components appropriate for the particular situation. Llahana and Hamric (2011) studied the role development experiences of diabetes specialist nurses (DSNs) in Great Britain who were not all master's prepared, although most held postgraduate qualification in diabetes care. Their findings indicated that role development phases were similar to those in Hamric and Taylor's earlier study (see Table 4.4). The anxiety experienced during the additional transition phase identified when an experienced DSN moved to a different practice site was related to orienting to a new work setting rather than to knowledge or competence in the role. Hamric and Taylor (1989) also described three negative phases not evident in previous literature. The frozen phase is described as being associated with frustration, anger, and lack of career satisfaction. Restructuring of role responsibilities and changing organizational expectations characterize the reorganization phase. The complacent phase is characterized by comfort, stability, and maintenance of the status quo. Unlike the integration phase, these additional phases share a negative, nonproductive character. It is of interest that there was a higher proportion of nurses in negative phases (58%) in the British study (Llahana & Hamric, 2011) than reported in the original Hamric and Taylor (1989) study (27%). One might speculate that APRNs experiencing these negative phases would be more vulnerable to position changes in today's cost-constrained health care system. APRN role development processes are further delineated by findings from Brown and Olshansky's (1997) study of the role transition experiences of novice NPs during their first year of practice. Their characterization of this role transition process as moving from “limbo to legitimacy” is supported by Cusson and Strange's (2008) finding that 1 year in practice constituted a consistent benchmark for NNPs moving from ambivalence to “making it as a real NNP” and by Sullivan-Bentz et al.'s (2010) observation that NPs transition from feeling overwhelmed to feeling confident by the end of the first year of practice. The four-stage process identified by Brown and Olshansky (1997) is outlined in Table 4.4. The first stage, laying the foundation, was not described in previous literature. During this stage, new graduates take certification examinations, obtain necessary recognition or licensure from state boards of nursing, and look for positions. This stage has been shortened because of the availability of online certification examinations. The second stage, launching, was defined as beginning with the first NP position and lasting at least 3 months. During this stage, the new graduate NP experiences the anxiety associated with the crisis of confidence and competence that accompanies taking on a new position and the return to the advanced beginner skill level (Benner, Tanner, & Chesla, 2009; Dreyfus & Dreyfus, 1986, 2009). As the advanced beginner becomes increasingly aware of the number of elements relevant to actual performance in the role, he or she may become overwhelmed with the complexity of the skills required for the role and exhausted by the effort required for mastery. New NPs in Kelly and Mathews' (2001) study described similar experiences of exhaustion and frustration with lack of control over time. This is the at-work version of the crisis of confidence and competence experienced during stage 1 of the in-school role acquisition process (Roberts et al., 1997). The feeling of being “an imposter” or “a fake,” described by Brown and Olshansky (1997), Arena and Page (1992), and Huffstutler and Varnell (2006), was first reported in the psychologic literature in reference to high-achieving women (Clance & Imes, 1978). Clinical symptoms associated with this phenomenon—generalized anxiety, lack of self-confidence, depression, and frustration—are commonly reported by APRNs experiencing the frustration phase or launching stage. It is related to feeling unable to meet one's own expectations and those of others (Clance & Imes, 1978) and feelings of inadequacy and constantly being tested (Arena & Page, 1992). This phenomenon is typically a temporary experience associated with taking on a new role or beginning a new job. The Heitz et al. (2004) study related similar role transition experiences of self-doubt, disillusionment, and turbulence and also reported that engaging in positive self-talk was helpful. They suggested that issues of gender and age may underlie differing perceptions of personal commitments and sacrifices as obstacles to surmount in role transition. Although Brown and Olshansky (1997, 1998) did not relate their findings about NP role transition to Hamric and Taylor's (1989) findings about CNS role development, there appear to be many similarities in the results of the two studies. The characteristics of Brown and Olshansky's launching stage are similar to those described by Hamric and Taylor for the frustration phase. Brown and Olshansky's third stage, meeting the challenge, is associated with feelings of regaining confidence and increasing competence. This stage has much in common with Hamric and Taylor's implementation phase, which is noted for returning optimism and enthusiasm as expectations are realigned. Brown and Olshansky's last stage, broadening the perspective, is characterized by feelings of legitimacy and competency as NPs. This last stage is similar to Hamric and Taylor's fourth phase of integration, during which the role is expanded and refined. The majority of NP role transition studies have been conducted with recent graduates; therefore, there are scant data to indicate whether or not NPs move on to the fourth phase of integration or develop any of the negative phases identified by Hamric and Taylor (1989) with CNSs or Llahana and Hamric (2011) with DSNs. Rich (2005) investigated the relationship between duration of experience as an RN and NP clinical skills in practice among NPs who graduated within 4 years from three universities in the Northeast. These graduates, 150 NPs, completed the self-report instrument assessments of their clinical skills (a response rate of 21%), and 60% of the collaborating physicians completed assessments of their NP clinical skills. Findings from the NP self-report data indicated that duration of practice experience as an RN was not correlated with level of competency in NP practice skills. “An unexpected finding was that there was a significant negative correlation between years of experience as an RN and NP clinical practice skills as assessed by the collaborating physicians” (Rich, 2005, p. 55). Data describing which role development phases the NP participants were experiencing or had experienced would have been helpful for enhancing understanding of the findings. The finding that collaborating physicians rated the NPs as more clinically competent than the NPs rated themselves (Rich, 2005) would be expected for NPs in the frustration phase or launching stage (see Table 4.4). Inclusion of assessments of role development and clinical competency in APRN follow-up studies would be helpful for building on the existing knowledge base. Whether the frozen, reorganization, and complacent phases are distinct developmental phases or variations of the implementation and integration phases, they are clearly negative resolutions for APRNs and their organizations. APRNs should engage in periodic self-assessment so that they recognize beginning signs associated with these phases, such as feelings of anger or dissatisfaction, conflict between self-goals and those of the organization or supervisor, feeling pressure to change one's APRN role in ways that are incongruent with one's concept of the role, and feelings of complacency. Early recognition of problems and taking proactive steps to adapt to organizational changes can help prevent or ameliorate the negative feelings associated with these phases. APRNs can keep track of their role transition process by setting specific time-limited goals, forming peer networks, and seeking out mentors. Further analysis of the relationships between the stages and phases of transitions during role implementation described here and outlined in Table 4.4 is needed. The relevance of these frameworks for transition processes experienced by other APRNs also needs study. It is promising to see some studies building on previous research. Further refinement of these findings could lead to their incorporation into APRN teaching, research, and practice and provide support for health care policy changes. Summary Observations on Transition Studies Following Graduation Examination of the findings from the diverse studies of APRN role transition following graduation in Table 4.4 leads to some important observations. Most studies are of recent APRN graduates and findings fairly consistently indicate a three-phase or three-stage process moving from advanced beginner competency to competency or proficiency during the first year of practice in terms of the novice-toexpert framework; from limbo to legitimacy in the Brown and Olshansky (1997) work; from frustration to implementation in the Baker (1979) and Hamric and Taylor (1989) work; or from ambiguity to role implementation in Chang, Mu, and Tsay's (2006) work. These studies indicate that the first year of APRN practice is commonly associated with a significantly difficult process of transition. APRN programs are designed to prepare graduates for beginning, entry-level clinical competency. The questionnaire study conducted by Hart and Macnee (2007) at two national NP conferences found that 51% of NPs perceived that they were only somewhat or minimally prepared for actual practice. The demands of the current health care system can be overwhelming for new APRNs coping with the transition to practice. Clinical residency programs have been developed recently to address role transition issues of new APRN graduates (Bush & Lowry, 2016; Flinter, 2012; Sargent & Olmedo, 2013; Thabault, Mylott, & Patterson, 2015). They are typically a year in length and are designed to enhance new graduate transition into practice, promote quality patient care, and increase NP retention and satisfaction. Flinter (2012) pointed out the need to advocate for federal funding to support graduate APRN residency training. The fact that graduate NP residents are licensed and certified and their services are billable can help to offset some of the costs of such programs. Strategies to Facilitate Role Implementation The phases described by Hamric and Taylor (1989) are used here to structure discussion of strategies to facilitate transitions during APRN role implementation (Table 4.5). The clinical residency programs for new graduates noted earlier constitute an overall approach for enhancing transition through the first three phases of postgraduate role implementation and ending with the fourth phase, integration. A national collaboration of NP organizations has recommended that these postgraduate programs be referred to as “fellowships” rather than “residencies” to minimize confusion because they are not required for entry into practice, as are clinical residencies for physicians (AANP NP Roundtable, 2014). TABLE 4.5 Strategies to Promote APRN Role Implementation in Practice Transition Phase Strategy Orientation Follow a structured orientation plan Circulate literature on APRN roles Network with peers Identify role model or mentor Join local, state, and national APRN groups Identify your expectations Frustration Schedule debriefing sessions with experienced APRN Discuss your expectations and how they fit in real-world application Plan for longer patient appointments initially Schedule administrative time Collaborate with other providers Learn time-saving tips Engage in positive self-talk Practice well-being habits of self-care Implementation Reassess demands, priorities, goals—modify expectations Schedule a 6-month evaluation Collaborate with other specialties—seek opportunities to co-treat with other specialties Learn from repetitive practice Learn ways to manage uncertainty Assemble mobile clinical resource applications Integration Schedule a 12-month evaluation Plan for role refinement and expansion Continue intraprofessional and interprofessional collaboration Continue debriefing sessions Continue seeking verification and feedback from colleagues Adapted from Table 4.4: Phases of Advanced Practice Nurse Role Development and Table 4.5: Transition Stages in First Year of Primary Care Practice. In: Brykczynski, K. A. (2014). Role development of the advanced practice nurse. In A. B. Hamric, C. M. Hanson, M. F. Tracy, & E. T. O'Grady (Eds.). Advanced practice nursing: An integrative approach (5th ed., pp. 98–100). St. Louis: Elsevier Saunders. Orientation Phase The importance of being patient and recognizing that it takes time to develop fully in a new APRN role was stressed by NPs in KleinpellNowell's surveys (1999, 2001). A strategy to facilitate role implementation for all APRNs during the orientation phase is development of a structured orientation plan (Goldschmidt, Rust, Torowicz, & Kolb, 2011). Sharrock, Javen, and McDonald (2013) described the contribution of clinical supervision to support nurses transitioning into new advanced practice roles. Brown and Olshansky (1997, 1998) noted the importance of clarification of values, needs, and expectations and of recognition that transitional experiences are timelimited. They also noted the importance of anticipatory guidance and realizing that these transition experiences follow a common pattern in new graduates. An APRN in a new position, whether experienced in the role or not, needs to be aware of the importance of being informed about the organizational structure, philosophy, goals, policies, and procedures of the agency. Networking was emphasized by NPs in Kleinpell-Nowell's surveys (1999, 2001; see also Kleinpell, 2005). Peer support within and outside of the work setting is important, as noted by Hamric and Taylor (1989). New NPs stressed the importance of getting to know other nurses in the work setting, gaining their respect, and forming key alliances with them to enhance optimal functioning in their new position (Kelly & Mathews, 2001). Designating a more experienced APRN in the work setting as a mentor can be helpful and provide support for any APRNs new to a position (Sullivan-Bentz et al., 2010). APRNs who serve as preceptors for students can be particularly effective mentors for new graduates (Hayes, 2005). The importance of careful selection of a mentor was reported by NPs in the study by Kelly and Mathews (2001). Additional strategies suggested for networking within the system include developing peer support groups, being accessible to colleagues by phone or email, and getting involved in interdisciplinary groups (Sullivan-Bentz et al., 2010). APRNs should be encouraged to join local APRN groups for peer support, legislative and political updates, and networking opportunities. Numerous Internet sites are also available for networking, as noted earlier. Page and Arena (1991) recommended that CNSs schedule and devote the major portion of their time during the orientation phase to direct patient care to solidify the clinical expert role. They also suggested making appointments with nursing leaders, physicians, and other health care professionals during this phase to garner administrative support. They recommended distributing business cards and making the job description available for discussion. They also counseled new CNSs to withhold suggestions for change until they have had the opportunity to assess the system more fully. When a new APRN joins the staff of an organization, the administrator should send a letter describing the APRN's background experiences and new position to key people in the organization. Frustration Phase Hamric and Taylor (1989) observed that the frustration phase might come and go and may overlap other phases. They noted that painful affective responses are typical of this difficult phase. They suggested that monthly sessions for sharing concerns with a group of peers and an administrator might facilitate movement through this phase. Strategies identified as helpful for energizing movement from the frustration phase to the implementation phase include the following: obtaining assistance with time management (Allen, 2001); participating in support groups to ameliorate feelings of inadequacy; engaging in discussions for conflict resolution and role clarification (Desborough, 2012); reassessing priorities and setting realistic expectations; and focusing on short-term, visible goals. Page and Arena (1991) suggested keeping a work portfolio to document activities so that APRN progress is more readily visible and accessible. This can be an expansion of the online portfolio and selfmonitoring system initiated during the APRN program. Brown and Olshansky (1997) noted that organized sources of support such as phone calls, seminars, planned meetings with mentors, and scheduled time for consultation can significantly decrease feelings of anxiety. They noted that recognition of the discomfort arising from moving from expert back to novice and the realization that previous expertise can be valuable in the new role may help reduce feelings of inadequacy. They suggested that new APRNs request reasonable time frames for initial patient visits because novices take longer than experienced practitioners, and this may be key to successful adjustment to a new position. Implementation Phase During this phase, it is important for the APRN to reassess demands and expectations to prevent feeling overwhelmed. Priorities may need to be readjusted and short-term goals may need to be reformulated. Brown and Olshansky (1997, 1998) observed that competence and confidence are fostered through repetition. They also recommend scheduling a formal evaluation after approximately 6 months in which feedback about areas of strength and those needing improvement can be ascertained. Strategies mentioned as important during this time include seeking administrative support through involvement in meetings, maintaining visibility in clinical areas, and developing inservice programs with input from staff (Page & Arena, 1991). After some time in the implementation phase, APRNs may plan and execute small-scale projects to demonstrate their effectiveness in their new role. Integration Phase Hamric and Taylor's (1989) survey data indicated that CNSs maximize their role potential during the integration phase, which typically occurs after 3 years in practice. Satisfactory completion of the earlier phases appears to be essential for passage into this phase. One strategy for enhancing and maintaining optimal role implementation during this phase is having a trusted colleague who can act as a safe sounding board for “feedback, constructive criticism, and advice” (Hamric & Taylor, 1989, p. 79). During this phase, it is important to have a plan to guide continued role expansion and refinement, such as the portfolio mentioned earlier. Seeking appointment to key committees is important to increase recognition of APRNs in the organization. Administrative support and constructive feedback from a trusted mentor continue to be important. Development of a promotional system that offers professional advancement in the APRN practice role through additional benefits or financial incentives remains a challenge for practitioners and administrators. International Experiences With Advanced Practice Nurse Role Development and Implementation: Lessons Learned and a Proposed Model for Success Over the last 20 years, as advanced practice nursing (APNa) roles have been introduced in other countries, there has been increasing interest in their role development and implementation internationally. There is more variability in advanced practice nursing internationally in terms of educational standards, scope of practice, credentialing, and the like. The Canadian experience provides significant lessons learned and suggestions for successful APN role implementation worldwide (Canadian Nurses Association, 2006). CNS and NP roles have existed in Canada for 40 years, but their implementation has been sporadic because of numerous system-level factors (DiCenso et al., 2010b; Sangster-Gormley, Martin-Misener, Downe-Wamboldt, & DiCenso, 2011). A decreased demand for APN roles in Canada resulted from many factors, including lack of legislative and regulatory authority of APN roles, multiple titles and conflicting definitions, absence of reimbursement mechanisms, opposition from the medical profession, and inconsistent curriculum requirements, which subsequently led to the gradual closure of most NP and CNS programs by the late 1980s (Sangster-Gormley et al., 2011). Recently there has been renewed interest in APN roles as a way to promote changes in the Canadian health care system (DiCenso et al., 2010b). Hurlock-Chorostecki, Forchuk, Orchard, Van Soeren, and Reeves (2014) investigated the role of NPs in Ontario hospitals and found that they contribute to building cohesive interprofessional teamwork. Doetzel, Rankin, and Then (2016) explored barriers and facilitators to NP practice in Canadian emergency departments with the goal of promoting their utilization in emergency department fast track units. Although external factors such as supports and barriers were addressed, the major focus of APN role development and implementation research has been on the micro level, with a focus on personal experiences of the individual clinician taking on a new role. A more comprehensive framework for role implementation developed in Canada is noteworthy in that it takes a macro perspective and involves stakeholders (e.g., administrators, patients, advocacy groups, support staff, professional organizations) in the APN role implementation process. It specifically addresses barriers to role implementation at the system, organizational, and practice setting levels (Bryant-Lukosius & DiCenso, 2004). The participatory, evidence-based, patient-focused process for APN role development, implementation, and evaluation (PEPPA) framework (BryantLukosius & DiCenso, 2004) recognizes the complexity of the system factors involved in implementing a new role in an existing system. The PEPPA framework (Fig. 4.2) incorporates the principles of participatory action research “to promote more equitable distribution of power and enhance the contributions of nurses, patients, and other stakeholders in APRN role development” (Bryant-Lukosius & DiCenso, 2004, p. 531). It was developed to guide APN role implementation and has been used effectively in a variety of practice settings in Canada (Martin-Misener et al., 2010; McAiney et al., 2008; McNamara, Giguère, St.-Louis, & Boileau, 2009). FIG 4.2 The participatory, evidence-based, patient-focused process for APRN role development, implementation, and evaluation (PEPPA) framework. (From Bryant-Lukosius, D., & DiCenso, A. [2004]. A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48, 532.) Facilitators and Barriers in the Work Setting Facilitators Aspects of the work setting exert a major influence on APRN role definitions and expectations, thereby affecting role ambiguity, role incongruity, and role conflict. The need for ongoing peer and administrative support is a theme throughout the literature on role development, beginning with the student experience and extending into practice. Administrative factors that should be considered include whether APRNs are placed in line or staff positions; whether they are unit-based, population-based, or in some other arrangement; who evaluates them; and whether they report to administrative or clinical supervisors. The placements of various APRN positions may differ, even within one setting, depending on size, complexity, and distribution of the patient population (Andrews et al., 1999; Baird & Prouty, 1989). Issues of professional versus administrative authority underlie the importance of the structural placement of the APRN within the organization. Effectiveness of the APRN role is enhanced when there is a mutual fit between the goals and expectations of the individual and the organization. Clarification of goals and expectations before employment and periodic reassessments can minimize conflict and enhance role development and effectiveness. Baird and Prouty (1989) maintained that the organizational design should have enough flexibility to change as the situation changes. Weiner (2009) described a theory of organizational readiness for change that can promote more flexible and promising approaches to improving health care delivery. Practical strategies identified by Bonnel, Belt, Hill, Wiggins, and Ohm (2000) for initiating NP practice in nursing facilities included proactive communication, developing a consistent system for visits, setting up the physical environment, and building a team approach to care. Credibility and advanced clinical nursing practice were recognized as facilitators by Ball and Cox (2004). Keating and colleagues (2010) noted that some organizations successfully increased their numbers of NPs by using measures such as reallocation of resources and creating a common nursing and medical budget. They encouraged continued exploration of role implementation issues and development of methods to address them to realize the potential benefits of NP practice to the health care delivery system. DiCenso and colleagues (2010a) delineated standardization of requirements, adequate resources, interprofessional education, legislation and regulation, needs assessment and understanding of role, stakeholder involvement, and a Pan-Canadian approach as factors enabling role integration of advanced practice nurses in Canada. Doerksen (2010) reported on a study of professional development and mentorship needs of advanced practice nurses in Canada that identified needs for both formal and informal mentorship and administrative support as important for full role implementation. Sargent and Olmedo (2013) described a funded postgraduate residency program that facilitated role transition for APRNs, improved their retention and satisfaction, and also enhanced quality of patient care. In their review of the process of reframing professional boundaries that occurs when new professional roles are introduced, Niezen and Mathijessen (2014) identified individual knowledge, skill and confidence, legislation, socioeconomic influences, and policy as factors that could be barriers or potential facilitators. The ability to incorporate teaching and counseling into the patient encounter may be a function of skill development gained with experience in the APRN role. This observation may be used as a rationale for structuring more time for visits and fewer total patients for new APRNs, with gradual increases in caseloads as experience is accrued. Older research has indicated that NPs incorporate counseling and teaching into the flow of patient visits—capturing the teachable moment (Brykczynski, 1999b; Johnson, 1993; Lurie, 1981). Demands to see more patients in less time can impinge on the possibility of incorporating more holistic aspects into patient encounters. Current and emerging delivery models that redesign primary care payment systems, moving from volume to value, and include incentives for patient-centered care performance and optimal outcomes are promising for APRNs because these payment systems highlight and support the additional dimensions of care that APRNs can provide (Calsyn & Lee, 2012). Barriers Factors found to impede NP role development include pressure to manage care for large numbers of patients, resistance from staff nurses, and lack of understanding of the NP role (Andrews, Hanson, Maule, & Snelling, 1999; Hupcey, 1993; Kelly & Mathews, 2001). Ball and Cox (2004) identified conflict, resistance, gender bias, political awareness, and established values as barriers to APRN role implementation. Keating, Thompson, and Lee (2010) reported on a study of perceived barriers to progression and sustainability of NP roles in emergency departments 10 years after they were introduced in Victoria, Australia. The main barriers identified were lack of organizational support, legislative constraints, and lack of ongoing funding for advanced practice nursing education. Lack of structured orientation programs was considered a barrier to APRN role transition by Goldschmidt and colleagues (2011). Sargent and Olmedo (2013) recognized limited time for physicians and experienced APRNs to mentor new APRNs as an impediment to APRN role development. Role confusion, lack of specific practice guidelines, and remuneration issues were barriers noted by Doetzel, Rankin, and Then (2016) with APRNs in the emergency department. Other constraints operating in today's health care settings that affect not only APRNs but also other providers and office staff include new billing and coding guidelines, Health Insurance Portability and Accountability Act regulations, major health care reform with a focus on outcomes, monitoring for fraud and abuse, sexual harassment, and demands to integrate technology into practice. Continued Advanced Practice Nurse Role Evolution CNMs, CRNAs, NPs, and CNSs have attained positive recognition and support in clinical positions in many settings in the United States. However, in spite of the increasing familiarity and popularity of these APRN roles, some health care settings have used few, if any, APRNs and some staff members have had minimal experience working with APRNs. In some areas of the United States, physicians or physician assistants are preferred over APRNs. Even experienced APRNs can expect to encounter resistance to full implementation of their roles if they seek positions in institutions with no history of employing APRNs. Andrews and colleagues (1999) described their experiences introducing the NP role into a large academic teaching hospital. They delineated helpful strategies for marketing a new NP role to staff, patients, and the surrounding community, as well as ways to set up the necessary infrastructure to support the new role in the institution. They referred to this process as evolutionary. The meaning of the evolution of established APRN roles varies according to the type of APRN role. The emphasis on cost containment in the health care delivery system led to the trend of having acute care NPs staff intensive care units to compensate for the shortage of house staff physicians (Rosenfeld, 2001; Sechrist & Berlin, 1998). Then ACNP practice broadened from an intensive care unit focus to diverse settings including specialty clinics and private practice groups (Kleinpell, 2005; Kleinpell-Nowell, 2001). Evolution of APRN roles is also reflected in the expansion of practice to multiple areas or sites. Although responsibility for multiple areas in the same facility has been typical of many CNS roles for years, it is an evolutionary process for most other APRN roles. Multisite roles might signify practice responsibilities at different sites or multiple areas of responsibility in the same site, and they may combine inpatient and outpatient responsibilities (Stahl & Myers, 2002). Stahl and Myers' clinical practices (Exemplar 4.2) are models for APRN practice evolving to multiple sites, which constitutes a strategy for extending APRN resources and trying to use them more efficiently. Exemplar 4.2 Evolving APRN Roles in Multisite Practices Expansion of practice to multiple sites is one way in which advanced practice registered nurse (APRN) practice is evolving, along with the integration of many health care delivery systems. Stahl is a clinical nurse specialist whose practice has evolved from the full range of clinical nurse specialist practice for four medical cardiac units at a tertiary care center to also include support primarily in education, consultation, and program development at two additional hospitals. Myers is an adult nurse practitioner who directs a hepatitis C program for a specialty physician group with 11 physicians at nine practice locations, and she also provides direct care for patients at four of the sites. Stahl and Myers (2002) relied on Quinn's (1996) wisdom for developing the leader within by expecting to “build the bridge as you walk on it” (p. 83) and learning “how to get lost with confidence” (p. 86). Their commitment to being continuous learners is a useful model for APRNs to follow as they experience the situational transitions that are inevitable as clinical practices evolve. Self-mastery and commitment are the keys to meeting the needs of a multisite practice. Setting realistic expectations, maintaining healthy personal and professional boundaries, and establishing attainable goals can contribute to success in multisite practice. Practice challenges such as supervision and role requirements may differ from institution to institution. Inconsistency in electronic health records creates challenges for documentation. Several systems require users to attend training sessions, while others are not fully integrated or are simply cumbersome to navigate. Hospital mergers and or acquisitions of solo practice and community clinics impose regulatory requirements on the APRN that may not have previously existed. APRNs are required to apply for privileges to practice in hospitals. This mandated credentialing process can take up to 12 weeks and limit practice until completed. Additionally, the onboarding processes in different institutions present APRNs with multiple challenges in policy and procedures not usually present in solo practice. Full practice authority has been granted to APRNs in federal programs, including the US Armed Forces, Indian Health Service, and Public Health Service systems, and in 24 states (National Council of State Boards of Nursing, 2016). Yet barriers preventing APRNs from practicing to the full extent of their education and training continue to exist (Hain & Fleck, 2014). The US Department of Veterans Affairs (VA) recently submitted a proposal granting APRNs full practice authority. There are over 5769 APRNs working within the VA system. On May 25, 2016, the VA proposed to amend its medical regulations to permit full practice authority of all VAemployed APRNs when they are acting within the scope of their VA employment (American Association of Colleges of Nursing, 2016; Brown, 2016; Federal Register, 2016; Japsen, 2016). The American Nurses Association, American Association of Nurse Anesthetists, American Association of Nurse Practitioners, and American Association Colleges of Nursing, along with state and local advanced practice organizations, rallied their members in positive response to this proposal. This national APRN campaign reached out to the public, asking for support and gaining recognition. This proposal was opposed by the American Medical Association and the American Society of Anesthesiologists (Brown, 2016). In a press release on December 14, 2016, the VA announced that it was amending provider regulations to permit full practice authority to three roles of VA APRNs to practice to the full extent of their education, training, and certification, regardless of state restrictions that limit such full practice authority, except for applicable state restrictions on the authority to prescribe and administer controlled substances, when such APRNs are acting within the scope of their VA employment. Unfortunately, CRNAs were not included in the VA's full practice authority under the final rule (US Department of Veteran's Affairs, 2016). As individual APRNs mature into their respective roles and become more competent and confident in all role components, greater concentration on the unique nature of APRN practice can be expected. In their study of CNSs, Hamric and Taylor (1989) found that freedom to develop their unique APRN role, availability of feedback from a mentor, support to broaden their influence and take on new projects, and recognition of their contributions enabled experienced CNSs to stay energized in their clinical practice roles. As Peplau (1997) advocated, nurse leaders must emphasize what nurses do for patients. The claim that APRN practice incorporates active patient participation, patient education, family assessment, involvement and support, and community awareness and connections (Neale, 1999) needs to be documented. For example, Kelly and Mathews (2001) found that graduates with 1 to 7 years of experience as NPs found it difficult to adhere to ideals of holistic care and health promotion, given the pressures of the clinical situation. Continued research that demonstrates positive outcomes of APRN care is essential for APRN practice to make an impact on health care policy (Brooten et al., 2002; Murphy-Ende, 2002; Russell, VorderBruegge, & Burns, 2002; Ryden et al., 2000; see also Chapter 23). Rashotte (2005) advocated for dialogic forms of research to evoke the more holistic and humanistic aspects of what it means to be an APRN to complement the predominant instrumental and economic perspectives underlying most APRN research. Brykczynski's (2012) interpretive phenomenologic study of how NP faculty incorporate holistic aspects of care into teaching NP students is an example of such dialogic research. More research activity and increasing involvement in the larger arena of health policy may also represent continuing role evolution for APRNs. The DNP is another example of APRN role evolution. The DNPprepared APRN brings an advanced skill set to health care with clear understanding of research and technology. DNP-prepared APRNs are educated to translate evidence into practice, promote collaboration and interprofessional teamwork, and advocate for change in health care policy to improve patient outcomes (Exemplar 4.3). Exemplar 4.3 DNP: The Changing Face of Health Care The Patient Protection and Affordable Care Act (2010) has had a significant impact on our health care system and has changed the face of primary care. Previously uninsured individuals with little or no health care in the last 10 to 20 years now have access to the health care system. This addition, along with an explosion of chronic illness coupled with the aging population, has resulted in an influx of patients presenting with complex clinical problems in primary care settings. The new face of health care supports the need for advanced clinical skills and leaders. Strong interprofessional collaboration is critical to successfully managing the current patient population. The doctor of nursing practice (DNP) responds to the need for advanced clinical skills and knowledge and increased collaboration with other disciplines at the systems level. DNP programs continue to grow in numbers (currently 246 in the United States) as employers recognize the contributions made by doctorally prepared APRNs (American Association of Colleges of Nursing [AACN], 2015a). DNP practice continues to evolve as new DNP graduates enter the health care system. Nurse entrepreneur, nurse executive, clinical educator, and nurse informatist are some of the positions being filled by DNP graduates. The evolution of the DNP role has contributed to the expansion of DNP programs and the adaptation of existing DNP programs to meet the changing needs of the health care system. Many DNP programs have implemented specialization paths (executive, informatics, and education) to prepare students for the diverse opportunities available. The specialization pathway is in its infancy and is not consistent across the country. All accredited programs are guided by the eight DNP essentials established by the AACN (2006). DNP preparation is empowering. Educated for professional leadership, the DNP-prepared APRN exemplifies the Institute for Healthcare Improvement's Triple Aim principles of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care (O'Dell, 2016; Stiefel & Nolan, 2012). Bodenhiemer and Sinsky (2015) identified a concern with widespread health care provider burnout and dissatisfaction and have recommended revision of the Triple Aim to a Quadruple Aim. The Quadruple Aim adds improving the work life of health care providers as another essential principle for enhancing patient care. The DNP is prepared with increased clinical and advocacy skills on which he or she can capitalize to effect policy change and quality improvement in health care. The new DNP-prepared APRN encounters a degree of uncertainty and anxiety while looking for the best career opportunity to demonstrate her or his advanced skills and knowledge (Glasgow & Zoucha, 2011). Many health professionals are unaware of the DNP-prepared APRN, and this degree has not achieved the level of equality expected with other practice doctorates as a result of role ambiguity, role conflict, and physician resistance. The lack of clarity adds to the role strain experienced by new DNP graduates. According to Glasgow and Zoucha (2011), the DNP is empowered with a broader perspective and an increased level of confidence, resulting in a decreased period of role transition. One might speculate that DNP-prepared APRNs move through the transitions in school and after graduation more quickly because of their advanced repertoire of both clinical and general life experience; however, further investigation is needed. DNP programs are growing, but individual DNPs will continue to face many challenges in the health care setting. The need for role clarity is paramount. As the number of DNP-prepared APRNs grows, their practice will continue to evolve and become more defined and accepted. DNP education is critical to advancing knowledge and clinical skills for advanced practice nurses (Hendricks-Ferguson, Akard, Madden, Peters-Herron, & Levy, 2015). The complexities of health care and advances in technology and research increase the need for the doctorally prepared APRN. Evaluation of Role Development Evaluation is fundamental to enhancing role implementation (see Chapter 24). Development of a professional portfolio to document APRN accomplishments can be useful for performance and impact (process and outcome) evaluation. Performance evaluation for APRNs should include self-evaluation, peer review, and administrative evaluation (Cooper & Sparacino, 1990; Hamric & Taylor, 1989). Use of a competency profile can be helpful for organizing evaluation in a dynamic way that allows for changes in role implementation over time as expertise, situations, and priorities change (Callahan & Bruton-Maree, 1994). APRNs can review the competency models available and select one to use for their ongoing competency profile (Sastre-Fullana, De Pedro-Gomez, Bennasar-Veny, Serrano-Gallardo, & Morales-Asencio, 2014). The competency profile can be used to assess performance in each of the core APRN competencies. APRN programs need to include content and skill development regarding self-evaluation and peer evaluation of role implementation so that individuals can learn to monitor their practice and identify difficulties early to avoid moving into negative developmental phases (Hamric & Hanson, 2003). Outcome evaluation is important to demonstrate the effectiveness of each APRN role, to document the impact of APRN practice on quality of care, and to overcome APRN invisibility (O'Grady, 2008). Ongoing development of appropriate outcome evaluation measures, particularly for patient outcomes, is important (Bryant-Lukosius et al., 2016; Ingersoll, McIntosh, & Williams, 2000; see Chapter 23). The existence of a reward system to provide for career advancement through a clinical ladder program and accrual of additional benefits is particularly important for retaining APRNs in clinical roles. In less structured situations, APRNs can negotiate for periodic reassessments and salary increases through options such as profit sharing. The evaluation process broadens to incorporate interprofessional review when APRN practice includes hospital privileges, prescriptive privileges, and third-party reimbursement. This expansion of the evaluation process has positive and negative aspects. Advantages to the review process associated with securing and maintaining hospital privileges include the many factors considered in the evaluation, the variety of perspectives, and the visibility afforded APRNs. APRNs should seek key positions on hospital review committees to promote APRN roles within the organization. A major difficulty in implementing interdisciplinary peer review is lack of interaction between and among the students of the various health professional groups during their formative educational programs. The resurgence of interest in developing and implementing interprofessional educational experiences between nursing students and medical students is encouraging (AACN, 2006; Hamric & Hanson, 2003; Institute of Medicine, 2003; Interprofessional Education Collaborative Expert Panel, 2011). Conclusion Role development experiences for APRNs are described as consisting of two distinct transition processes: the first is referred to here as role acquisition, which occurs in school, and the second as role implementation, which occurs in practice after graduation. The limits of the educational process in preparing graduates for the realities of the work world are acknowledged. Students, faculty, preceptors, and administrators need to be informed about the human skill acquisition process and its stages, processes of adult and professional socialization, identity transformation, role acquisition, role implementation, and overall career development. Knowing (theoretical knowledge) and actually experiencing (practical knowledge) are different phenomena, but at least students and new graduates can be forewarned about the transition experiences in school and the turbulence that can be expected during the first year of practice. Anticipatory guidance for students can be provided through role rehearsal experiences, such as clinical preceptorships and role seminars. Students need to be encouraged to begin networking with practicing APRNs through local, state, and national APRN groups. This networking is especially important for APRNs who will not be practicing in proximity to other APRNs. Experienced APRNs and new APRN graduates can form mutually beneficial relationships. Although anticipatory socialization experiences in school can facilitate role acquisition, they cannot prevent the transition that occurs with movement into a new position and actual role implementation. APRN programs should have a firm foundation in the real world. However, a certain degree of incongruence or conflict between academic ideals and work world reality will continue to exist (Ormond & Kish, 2001). APRNs must take a leadership role in guiding and directing planned change and guard against the mere maintenance of the status quo. Establishing mentor programs, structured orientation programs, and postgraduate fellowship programs for new APRNs in the work setting are ways to develop and maintain support for the positive developmental phases of role implementation and minimize role strain. APRN role development has been described as dynamic, complex, and situational. It is influenced by many factors, such as experience, level of expertise, personal and professional values, setting, specialty, relationships with coworkers, aspects of role transition, life transitions, and organizational, system, and political realities. Frameworks for understanding APRN role development processes have been discussed, along with strategies for facilitating the dual transitions of role acquisition in school and role implementation upon graduation. Ongoing evolution of APRN roles in response to organizational and health care system changes and demands will continue. Future research studies to assess the applicability of this information to all APRN specialty groups are needed to further the understanding of APRN role development, guide educational and work setting innovations, and support health policy recommendations. Key Summary Points ■ Application of the Dreyfus Situational Model of Skill Acquisition to APRN role development depicts the acquisition of skills and knowledge as developing over time in stages from novice to expert, with the whole process evolving over time in cycles of progression and regression occurring as new skills and knowledge are acquired and new situations are encountered and mastered. ■ APRN role development consists of two distinct processes: (1) Role acquisition is the process of APRN role transition that takes place during the APRN educational program. 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JAMA: The Journal of the American Medical Association. 2012;308(13):1327–1328. a The acronym APRN is only used in the United States; therefore the acronym APN will be used for this international section of the chapter. CHAPTER 5 Evolving and Innovative Opportunities for Advanced Practice Nursing Jeanne Salyer “The best way out is always through.” —Robert Frost CHAPTER CONTENTS Patterns in the Evolution of Specialty Nursing Practice to Advanced Practice Nursing, 109 Innovative Practice Opportunities (Stage I), 111 Hospitalist Practice, 112 Commentary: Stage I, 112 Specialties in Transition (Stage II), 113 Clinical Transplant Coordination, 113 Forensic Nursing, 115 Commentary: Stage II, 118 Emerging Advanced Practice Nursing Specialties (Stage III), 118 Interventional Pain Practice, 118 Wound, Ostomy, and Continence Nursing, 119 Commentary: Stage III, 120 Established Advanced Practice Nursing Roles (Stage IV), 122 Advanced Diabetes Manager, 123 Genetics Advanced Practice Nursing, 124 Commentary: Stage IV, 125 Conclusion, 125 Key Summary Points, 128 Technologic advances and economic and sociocultural conditions have sustained a climate of change in the health care environment, and opportunities for advanced practice nursing continue to emerge in the wake of these changes. As specialties have emerged, many new roles have evolved from specialty nursing practice and have expanded to incorporate some or all of the core attributes of advanced practice nursing (see Chapters 2 and 3). Some of these roles have clearly evolved as advanced practice roles, whereas others are in various stages of evolution. Not all specialties, however, will evolve into advanced practice roles, for a variety of reasons. For example, some specialties evolve away from the core definition of advanced practice nursing, which encompasses direct clinical practice and clinical expertise as essential ingredients. Other specialties, such as informatics and nursing administration, arise as specialties and remain as specialties because direct clinical practice is not a requisite role component. The purpose of this chapter is to examine some currently evolving specialties and characterize stages in their continuing evolution from specialty nursing practice to advanced practice nursing. Some of these specialties have not yet fully evolved to an advanced level; however, movement within the specialty toward advanced practice may be accelerated as Doctor of Nursing Practice (DNP) programs target these specialties for development. The focus of the discussion is on the various specialties—not on particular advanced practice nursing roles, such as clinical nurse specialist (CNS), nurse practitioner (NP), certified nurse-midwife, or certified registered nurse anesthetist (CRNA). Specialties selected for inclusion in this discussion were chosen for one or more of the following reasons: • The specialty has the potential to transition (or is transitioning) to the DNP. • The specialty has the potential to evolve to advanced practice nursing, given the complexity of care required by the patient population, and direct care is likely to be a defining factor. • The specialty has arisen as a result of scientific and/or technologic advances and the influence of these advances on the delivery of health care. • The specialty is growing because of the rising incidence of health problems in the population. • The specialty's patient population needs sophisticated care across settings in the complex health care environment. Opportunities in these evolving specialties for advanced practice registered nurses (APRNs) are discussed and a framework for evaluating progress toward advanced practice status is presented. Exemplars provided by APRNs in the specialties were deliberately chosen to illuminate the added value of advanced practice competencies to these evolving specialties. Patterns in the Evolution of Specialty Nursing Practice to Advanced Practice Nursing Before discussing the evolution of specialty nursing practice into advanced practice nursing, it is important to make a distinction between the two as well as to clarify the use of the term subspecialty in this chapter. Specialization involves focusing on practice in a specific area derived from the field of professional nursing. Specialties can be further characterized as nursing practice that intersects with another body of knowledge, has a direct impact on nursing practice, and is supportive of the direct care provided to patients by other registered nurses (American Nurses Association [ANA], 2010a). As the profession of nursing has responded to changes in health care, the need for specialty knowledge has increased. For example, in the wake of the National Cancer Act of 1971, which was enacted as a consequence of the increasing incidence of cancer in the population and the need to advance national efforts in prevention and treatment, the oncology specialty became more widely recognized (Oncology Nursing Society [ONS], 2016). The ONS traces its origin to the first National Cancer Nursing Research Conference, supported by the ANA and American Cancer Society, in 1973, after which a small group met to discuss the need for a national organization to support their professional development. From these early efforts, this organization, which was incorporated in 1975, has become a leader in cancer care in the United States and around the world (ONS, 2016). The classic specialties in nursing, now termed populations in the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008), have been pediatric (now termed child health), psychiatric and mental health, obstetrics (now termed women's health), community and public health, and medical-surgical nursing (now termed adult health). Specialties that have emerged within these populations include, for example, concentrations in adult and pediatric critical care, emergency, and oncology nursing. As a given specialty coalesces, nurses often form specialty nursing organizations out of clinicians' needs to share practice experiences and specialty knowledge. Some examples include the American Association of Critical-Care Nurses, the ONS, and the Association of Women's Health, Obstetric and Neonatal Nurses. Scope and standards of practice statements legitimize specialty designation and prompt efforts to provide opportunities for specialty education and certification. The efforts of the International Transplant Nurses Society (ITNS) to develop and approve a scope of practice statement, a core curriculum, and specialty certification in transplant nursing for registered nurses is just one example (ITNS/ANA, 2009; ANA/ITNS, 2016). Advanced practice nursing includes but goes beyond populationfocused specialization; it involves expansion, which legitimizes role autonomy, and advancement, characterized by the integration of a broad range of theoretical, research-based, and practical knowledge (ANA, 2010a; see Chapter 2). Thus advanced practice nursing reflects concentrated knowledge that offers the opportunity for expanded and autonomous practice based on a broader practical and theoretical knowledge base. The term specialty suggests that the focus of practice is limited to parts of the whole (ANA, 2010b). For example, family NPs, who typically see themselves as generalists, have in fact specialized in one of the many facets of health care—namely, primary care. Subspecialization further delineates the focus of practice. In subspecialty practice, knowledge and skill in a delimited clinical area is expanded further. With this expanded knowledge and skill, there is potentially further advancement of theoretical, evidence-based, and practical knowledge in caring for a specific patient population base. Examples of subspecialty practices within the specialty of adult health nursing include diabetes, transplant, and palliative care nursing. Notably, most of the practice opportunities chosen for discussion in this chapter are subspecialty practices. This distinction between specialty and subspecialty is important, particularly for certification and regulatory reasons, and was codified when the National Council of State Boards of Nursing (NCSBN) proposed the regulation of advanced practice nursing in terms of certification requirements at the broad population foci level (e.g., psychiatric and mental health, pediatrics, adult and gerontology), with specialty or subspecialty certification being voluntary (NCSBN, 2008). Regulatory considerations aside, the expansion of advanced practice nursing is increasingly occurring in specialty and subspecialty practice. Expanding these boundaries places APRNs on the cutting edge of clinical care delivery in a complex, ever-changing, health care environment. However, for the sake of consistency with the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008), in the remainder of this chapter, specialty and subspecialty practice are referred to as specialties. From a historical perspective, the evolution of specialty nursing practice to advanced practice nursing follows a trajectory that has been described by several authors (Beitz, 2000; Bigbee & AmidiiNouri, 2000; Hamric, 2000; Lewis, 2000; see Chapter 1). Hanson and Hamric (2003) synthesized these observations and characterized this evolution as having distinct stages (Table 5.1). Initially, in stage I, the specialty develops in response to changing patient needs, needs that are usually a result of new technology, new medical specialties, and/or changes in the health care workforce. For example, a lack of pediatric residents and the increasing number of neonatal intensive care units created an opportunity for the development of the neonatal NP role (DeNicola, Klied, & Brink, 1994; Honeyfield, 2009). TABLE 5.1 Four Stages in the Evolution of Advanced Practice Nursing Stage Description Characteristics I Specialty begins Specialty develops in practice settings; development driven by increasing complexity in care demands, new technology, changing workforce opportunities; on the job training, expansion of practice; not exclusively nursing II Specialty organizes Organized training for specialty practice begins; institution-specific training develops; initially uses apprenticeship model; progresses to certificate training; specialty organization forms; certification examination develops but may not be nursing specific; reports appear on role of nurse in specialty III Pressures mount for standardization Knowledge base grows; pressures mount for standardization, graduate education; knowledge base keeps growing, scope of practice expands for practitioners in the specialty; expanded practice leads to expanded regulatory oversight; leaders call for transition to graduate education and differentiated practice to standardize practice in the specialty; advanced practice registered nurses (APRNs) migrate to specialty or specialty nurses return to school; reports appear differentiating APRN role in the specialty IV Maturity and growing APRN practice in the specialty is well articulated, recognized by other interprofessionalism providers; APRNs practice collaboratively with other practitioners in the specialty; APRNs are experts in the specialty or subspecialty; shared knowledge base with other health care professionals recognized; multidisciplinary certification examinations developed Adapted from Hanson, C. M., & Hamric, A. B. (2003). Reflections on the continuing evolution of advanced practice nursing. Nursing Outlook, 51, 203–211. Stage II of development is characterized by progress to the point that organized training begins. This training is often institutionspecific, on-the-job training that develops experts in the specialty. Some of these institution-specific programs develop into certificate programs; however, the content may not be standardized, and the quality of these specialty programs may vary. One example is the early transplant coordination role in major transplant centers (see “Clinical Transplant Coordination” later). In stage III, the knowledge base required for specialty practice becomes more extensive and the scope of practice of the nurse with specialty training expands. There is growing recognition of the additional knowledge and skill needed for increasingly complex practice. It is not unusual at this stage to see APRNs migrate into an evolving specialty and further expand practice by infusing it with advanced practice core competencies, making the specialty resemble advanced practice and creating new calls for evolution to this higher level. This transition is clearly evident in wound, ostomy, and continence nursing (see “Wound, Ostomy, and Continence Nursing” later) as well as in palliative care nursing. Over time, pressure for the standardization of education and skills involved in the specialty arise from clinicians, the profession, and regulators. Certificate-level training programs move into graduate schools that assume responsibility for preparing nurses for these evolving specialties, improving standardization, elevating the status of the specialty, and fostering its emergence as an advanced practice role. In this third stage of the trajectory, graduate education becomes an expected level of preparation (Hanson & Hamric, 2003). Stage IV, initially described by Salyer and Hamric (2009), is characterized by mature and recognized APRN practice in the specialty, along with an emerging understanding of a shared interprofessional component. NPs in human immunodeficiency virus (HIV) practice who have attained certification as an HIV specialist, awarded by the American Academy of HIV Medicine, are an example of mature expert practitioners who share an interprofessional clinical knowledge base with physicians in this specialty. It is important to note that these stages are dynamic and not mutually exclusive. It is not unusual for specialties to show characteristics of more than one stage simultaneously (e.g., graduate programs began to develop at the same time that most practitioners in the specialty were prepared in certificate programs). In addition, the duration of each stage may vary significantly by specialty. Thus, the evolution from specialty to advanced practice nursing can represent a natural maturation that should result from deliberate logical planning to strengthen the education and broaden the scope of practice of specialty nurses. Some of these roles evolve to fulfill the needs of specific patient populations or the needs of organizations. In some cases, changes in the legal recognition and regulation of practice also influence the movement toward advanced practice nursing. For example, the nurse-midwifery specialty moved toward requiring graduate-level educational preparation for their practitioners in response to the national movement among state boards of nursing to require this level of education for all APRNs. Complex and often controversial issues must be addressed before and during this evolutionary process (Box 5.1). In the following sections, the evolution of particular specialties to advanced practice nursing is described and these issues are discussed. Some of these specialties are struggling to evolve, and change is haphazard. Others are following a planned course of action and have emerged (or will soon do so) at the advanced practice level. All evolving specialties share two challenges —the need to gain support within and external to nursing for these roles and the need to clearly delineate their potential contributions in the health care environment. Box 5.1 Issues in the Evolution of Specialty Nursing Practice to Advanced Practice Nursing • Defining the attributes of advanced practice in the specialty • Delineating the core competencies of the specialty as encompassing the core competencies of advanced practice • Delineating a vision of advanced practice that may step outside of nursing's traditional vision of what constitutes an advanced practice role and gaining support within the nursing and health care community for the role • Standardizing curricula for achieving competency at the advanced practice level • Clarifying certification and credentialing requirements • Overcoming legal and regulatory issues that are barriers to patient and/or consumer access to advanced practice registered nurses (APRNs) • Promoting recognition of APRNs and nursing as a profession • Clarifying APRN role titles to be consistent and decrease confusion Adapted from Hanson, C.M., & Hamric, A.B. (2003). Reflections on the continuing evolution of advanced practice nursing, Nursing Outlook, 51, 203–211. Innovative Practice Opportunities (Stage I) The initial stage of the evolution from specialty practice to advanced practice is characterized by the development of a specialty focus. Numerous examples are apparent in the history of nursing, which is replete with accounts of nursing's response to unmet patient needs. As a consequence, definable specialties emerge as nurses expand their practice to include the knowledge and skills necessary to meet the needs of patients requiring specialty care. Examples from our history include the specialty of enterostomal therapy nursing, now known as wound, ostomy, and continence (WOC) nursing, and forensic nursing, which has historically encompassed care provision in correctional facilities, psychiatric settings, and emergency departments as nurse examiners care for sexual assault and child abuse victims (Burgess, Berger, & Boersma, 2004; Doyle, 2001; Hutson, 2002; Maeve & Vaughn, 2001; McCrone & Shelton, 2001). As specialties begin to coalesce, the practice may not be viewed as a nursing role. For example, early enterostomal therapists were laypersons with ostomies. However, as the specialty evolved, the valuable contributions of nurses began to distinguish them from other care providers. Several evolving roles in nursing are characterized as being innovative. Some of these roles do not reflect the core competencies of advanced practice nursing, and the role components differ significantly, in some cases, from those of an APRN. For example, if the focus of practice in forensic nursing had remained on the gathering of legal evidence, not on sustained clinical practice using advanced practice core competency elements, the role would not be evolving to an advanced practice level. Regardless, nurses functioning in these subspecialties, some of whom are APRNs, make unique contributions to the health of specific populations of patients. One such role to be explored as a stage I specialty is that of the hospitalist. Hospitalist Practice The development of the hospitalist movement over the past 20 years represents a break in the tradition of primary care physicians managing patients in inpatient and outpatient settings. In this model, inpatients are cared for by what is termed a hospitalist physician—a term coined by Wachter and Goldman (1996)—whose primary professional focus is the general medical care of hospitalized patients (Park & Jones, 2015). The hospitalist model, which is now expanding to include pediatric hospitalists, surgical hospitalists, neurologic hospitalists, obstetric-gynecologic hospitalists, orthopedic hospitalists and other specialty hospitalists (American Hospital Association [AHA]/AHA Physician Leadership Forum/ Society of Hospital Medicine [SHM], 2012), has grown rapidly as a result of the role of managed care in organizations, increasing complexity of inpatient care, fragmentation of care, and pressures experienced by physicians in busy outpatient practices (AHA/AHA Physician Leadership Forum/SHM, 2012; Freed, 2004; SHM, 2016a; Wachter, 2004; Wachter & Goldman, 2016). In this model, inpatient management is voluntarily transferred by the outpatient physician to the hospitalist during the hospital admission and, on discharge, care is resumed by the outpatient physician. The literature on hospitalist medicine discusses characteristics of hospitalists that are very similar to those of adult-gerontology acute care nurse practitioners (AG-ACNPs). This evolving paradigm of providers caring exclusively for acutely ill hospitalized patients provides opportunities for APRNs to work on the hospitalist team (Kleinpell, Hanson, Buchner, Winters, Wilson, & Keck, 2008; see Chapter 16). As part of a hospitalist team, which some suggest requires advanced training (Furfari, Rosenthal, Tad-y, Wolfe, & Glasheen, 2014), this APRN diagnoses acute and chronic conditions that may result in rapid physiologic deterioration or life-threatening instability, works collaboratively with a variety of health care professionals, promotes efficient use of resources, and provides quality care to achieve optimal cost-effective outcomes (American Association of Critical-Care Nurses, 2012; National Panel for Acute Care Nurse Practitioner Competencies, 2004). These specific functions illuminate the centrality of direct care practice of APRNs in this specialty. As the APRN hospitalist specialty continues to evolve, the added value of practice guided by acute care competencies has the potential to improve the quality of care received by hospitalized patients. The SHM, with over 15,000 members, is a multidisciplinary organization (physicians, physician assistants [PAs], NPs). This organization is dedicated to supporting the growth and development of NPs and PAs in hospital medicine and recognizes the contributions of these providers and, through the Nurse Practitioner/Physician Assistant Committee, is developing initiatives and programs to promote and define the role of these providers in hospital medicine (SHM, 2016b). As the role of NPs and PAs continues to evolve, hospitalist practice will become more interprofessional, and APRNs and PAs will continue to be members of collaborative hospitalist teams to provide differentiated levels of care in the inpatient setting. Commentary: Stage I Hospitalist practice has clearly emerged as a specialty in medicine. Although NPs, particularly and most appropriately AG-ACNPs, are beginning to practice in this specialty, it is a stage I specialty for two reasons. First, the specialty is not yet recognized as a nursing specialty, and, although hospitalist practice for NPs has been defined by at least one state (Sullivan, 2009), describing unique distinctions between an APRN hospitalist and physician hospitalist has not yet been attempted. Second, APRN preparation for hospitalist practice is continuing to evolve as graduate nursing programs develop competency-based curricula more fully, with practica aimed at the development and refinement of knowledge and skills required for acute care, inpatient practice. One challenge for this stage I specialty is to clearly articulate the unique contributions that APRNs can bring to the care of hospitalized patients, which may decrease fragmentation of care and improve interprofessional collaboration and overall patient outcomes. In addition, graduate nursing programs offering acute care education can ensure that hospital practice, based on the identified competencies in hospital medicine (Dressler, Pistoria, Budnitz, McKean, & Amin, 2006) and AG-ACNP competencies (American Association of Colleges of Nursing, 2012), are incorporated into required clinical practica. The challenge to any APRN moving into this specialty is to maintain APRN competencies and avoid a practice that is strictly an extension of medical practice. This transition may be facilitated if acute care nursing organizations promote and support establishment of special interest groups to facilitate these transitions and collaborate with the SHM on the development of certification processes for those APRNs with appropriate national credentials (Exemplar 5.1). Exemplar 5.1 APRN Hospitalista The Hospital Medicine Nurse Practitioner Service at Strong Memorial Hospital, University of Rochester Medical Center, was started in 1995 as an initiative to reduce length of stay. Four nurse practitioners (NPs) were hired, along with a hospitalist, to start a short-stay unit. Patients included those with myocardial infarction rule-outs, new-onset atrial fibrillation, and simple cellulitis, as well as those needing observation after procedures. The NPs covered the unit 10 hours/day, 5 days/week, with fellows and other house staff covering the remaining hours (M. A. Terboss, personal communication, 2007). Since its inception, the service has grown exponentially, primarily in response to the reduced number of medical resident positions and tighter restrictions on resident work hours by the Accreditation Council on Graduate Medical Education. In addition, the team's census grew along with the hospital census when two hospitals in the city closed. Other changes included an increase in patients, the addition of physician assistants to the team, and orthopedic surgery patients attended to by the Hospital Medicine Service. The service has expanded to cover patients on 15 patient care units, 24 hours/day, 7 days/week, including holidays. The specialty of hospital medicine is relatively new, and therefore the role of the acute care nurse practitioner (ACNP) in a hospitalist role varies from hospital to hospital. At Strong Memorial, ACNPs have a variety of roles and responsibilities. They collaborate with the Hospital Medicine Division physicians and community-based primary care providers and share responsibility for examinations, documentation, order writing, and discharge planning. The ACNPs also follow patients admitted to subspecialty services, such as gastroenterology, nephrology, cardiology, and infectious diseases. Whereas the subspecialist attending physician or fellow may focus on the organ of interest, the ACNP independently manages comorbidities, updates families, and coordinates care, all of which provide a more holistic perspective to the patient's hospital stay. Concrete defined tasks include admitting histories, physical examinations, orders, discharge instructions and summaries, and a daily visit with a progress note. ACNPs order and interpret diagnostic and laboratory tests, participate in multidisciplinary unit rounds, and update an electronic sign-out system for safer handoffs. Procedures such as line placement are usually provided by residents as part of their educational experience. Many of the ACNP's responsibilities are less easily defined or measured. However, in these functions, the ACNP adds value to the care provided by the Hospital Medicine Service. They include coordination of care among the variety of consultants, other health professionals (e.g., physical therapists, nutritionists, social workers), and unit management. In addition, ACNPs update patients and families to maintain open communication and keep them informed of the care plan. They also orient new ACNPs to their role and mentor ACNP students. Most importantly, ACNPs collaborate with the bedside nurses and unit staff. Communication of updates, orders, and plans is essential to ensuring safe, timely, and quality care. The accessibility of the ACNP promotes collaboration and many opportunities for informal teaching. As APRNs, ACNPs are often the most knowledgeable about medication information, technology management, or even basic nursing care and can serve as resources for newer, less experienced nurses. Teaching and mentoring are important to ensure staff development and retention as well as safe patient care. The importance of these activities has been difficult to quantify. It has been and continues to be a challenge to the Hospital Medicine Service to measure these contributions and illustrate their value. The future for ACNPs on hospital medicine teams is promising. The specialty is growing, along with the acuity of inpatients and the complexities of discharge planning, both of which ACNPs are well- suited to manage. ACNP programs are incorporating hospital medicine into their curricula and into clinical rotations. The ACNPs on the Hospital Medicine Service have precepted many of these students, some of whom have gone on to join our team. Many challenges are ahead, including finding ways to quantify our contribution in terms of quality of care, length of stay, and patient and staff satisfaction. Orienting new ACNPs to handle the complexity of these inpatients and recruiting for 24 hours/day, 7 days/week positions is also a challenge. I find my role as an ACNP on the Hospital Medicine Service to be highly satisfying because I care for patients with a wide variety of health problems. I also have the opportunity every day to teach, learn, and make a difference for a patient or another nurse. Finally, it is very rewarding to work on a team of APRNs who are so dedicated to hospital medicine, providing excellent patient care and supporting and helping each other. I am proud to be an ACNP in hospitalist practice. a The author gratefully acknowledges Elizabeth Palermo, MS, RN, APRN-BC, Rochester, New York, for assistance with this exemplar. Specialties in Transition (Stage II) Stage II roles are characterized by progress in the evolution of the specialty to the point that organized training in the specialty begins. This training is often institution-specific, on-the-job training that develops experts in the specialty. The two roles discussed as demonstrating predominantly stage II characteristics but that may exhibit some characteristics of stage III are those of the clinical transplant coordinator (CTC) and forensic nurse (see Table 5.1). Clinical Transplant Coordination There is mounting evidence that the role of the CTC is evolving to the level of advanced practice nursing in response to patient care requirements in the referral and evaluation phase for patients, their families, and living donors, and in the pretransplant and posttransplant management phases of candidates and recipients. Specialty nurses with expertise in transplant nursing recognize the complex needs of these patients and many obtain graduate education to prepare themselves better to deal with the realities of transplant nursing. To the benefit of their patients, these coordinators have expanded the specialty by incorporating advanced practice core competencies. Two organizations provide opportunities for ongoing education and preparation for certification for nurses who provide care for transplant patients, the North Atlantic Transplant Coordinators Organization (NATCO) and the ITNS. NATCO provides organized education in the specialty for clinical and procurement transplant coordinators (NATCO, 2016a) in preparation for certification by the American Board for Transplant Certification (2015). The ITNS, an organization focusing on the professional growth and development of the transplant clinician (ITNS, 2016), provides education on advances in transplantation and transplant patient care. The ITNS has published a core curriculum (Ohler & Cupples, 2007) and a scope and standards of practice statement (ANA/ITNS, 2016) for the specialty that incorporates core competencies. Unlike the NATCO core competencies for the advanced practice transplant professional (APTP), which define the APTP as a provider who is not a physician but is licensed to diagnose and treat patients in collaboration with a physician (NATCO, 2016b), the scope and standards of practice statement developed by the ITNS (ANA/ITNS, 2016) clearly addresses the scope of practice for transplant nurses, clinical and procurement transplant coordinators, and advanced practice transplant nurses, both NPs and CNSs. Building on the practice of the registered nurse generalist in transplant care and transplant nurse coordinator by demonstrating a greater depth and breadth of knowledge, greater synthesis of data and interventions, and significant role autonomy, which may include medical diagnosis and prescriptive authority, APRNs working in transplant centers integrate and apply a broad range of theoretical and evidence-based knowledge using specialized and expanded knowledge and skills (ITNS, 2016). It can be argued that the complex needs of patients with end-stage organ disease require higher levels of clinical reasoning and analytic skills, such as those possessed by APRNs; however, to advance the CTC role (not just individuals in the role) to this higher level, attention to several issues is necessary. First and foremost, leaders in this specialty must systematically determine whether advanced practice core competencies (see Chapter 3) are required to enact the role fully or whether two levels of differentiated practice—generalist professional and APRN—should be defined. Second, the specialty's leadership must agree that the role is a nursing role. Because some CTCs are not nurses, making these decisions may disenfranchise many committed and experienced transplant professionals who are essential care providers. Similar to the different certifications in place for diabetes educators and advanced diabetes managers, a similar method of differentiation, recognizing the added value that advanced practice knowledge and skill brings to the CTC role, might serve to acknowledge the contributions of APRNs and other transplant professionals. Both the ITNS and NATCO are moving in this direction by doing the following: (1) delineating the core competencies required for clinical and procurement transplant coordinators (ANA/ITNS, 2016; NATCO, 2016a); (2) developing a core curriculum for transplant nursing at the generalist level (Ohler & Cupples, 2007); and (3) as of 2004, initiating a certification examination for the clinical transplant nurse (certified clinical transplant nurse [CCTN]) (American Board for Transplant Certification, 2015). Institution-specific, on-the-job education and experience, attributes that characterize a stage II specialty, continue to be widely embraced in the specialty; however, efforts to provide more formalized education are now the standard. Specialty certification is an issue for all evolving advanced practice nursing specialties. Educational institutions that prepare APRNs must consider the certification requirements and ensure that their graduates are eligible to sit for APRN certification examinations approved for legal recognition of an APRN role. Specialty certification offered by specialty organizations, although optional, demonstrates a knowledge base shared among clinicians in the specialty and improves clinical credibility. The evolution toward advanced practice nursing for the CTC has been haphazard as a result of inattention to several issues. Most notably, the lack of recognition that the role requires advanced practice competencies and the lack of opportunities for advanced practice specialty certification may impede expansion into advanced practice nursing as an expectation of coordinator roles. The issue of specialty certification (at the generalist level) has been addressed, but no plans for advanced practice certification have been proposed, except for the APTP. Clearly, however, there is a commitment to advanced practice nursing in transplantation and, given that commitment, more attention to these issues will be necessary for the CTC role to evolve to stage III. Exemplar 5.2 demonstrates the complexity of care required for transplant candidates, recipients, and their families. In addition to expertise in advanced practice core competencies, the exemplar also highlights the skill of the APRN in dealing with systems issues—in the hospital and community—and staff education and coaching, both of which are important components of providing care to this challenging patient population. Collaboration as a member of a team of care providers affords the opportunity to advocate for patients and their family members and influence quality of care. Thus, the knowledge and expertise of advanced practice nurses could fully enable the potential of the CTC position. Exemplar 5.2 Clinical Transplant Coordinatora Organ transplantation remains the treatment of choice for end-stage disease involving the heart, kidney, liver, and lung. Additionally, transplantation of the bowel and pancreas are performed in select patients to treat intestine failure (whether function or surgical) and type 1 diabetes mellitus, respectively. In 2015, over 30,000 solid organ transplants were performed in the United States (Organ Procurement and Transplantation Network, 2016). The complexity of care, both before and after organ transplantation, requires that an interprofessional team provide care to the patient. Surgeons, physicians, social workers, pharmacists, nurses, advanced practice registered nurses (APRNs), and psychologists evaluate and treat both the candidate and the organ recipient. The role of the transplant coordinator is to facilitate the care of the patient by collaborating with the interprofessional team and ensuring appropriate delivery of care. This process begins with initial referral to the transplant program, proceeds through the evaluation process and transplant surgery, and continues as long as the patient maintains care at the transplanting institution. Currently, many transplant coordinators throughout the country are advanced practice nurses. Whether clinical nurse specialist or nurse practitioner, the APRN is prepared by advanced education to facilitate the transplant evaluation process, determine patient acuity as well as the specific needs of the candidate, collaborate with colleagues on the interprofessional team, monitor changes in the candidate's health during the organ waiting period, facilitate the transplant procedure, assess the patient's health status during recovery from surgery, participate in care planning, and provide discharge teaching to the patient and family. Following discharge, the APRN coordinates care as required by the type of organ transplant (arrangement of biopsies, clinic visits, specialized testing) and serves as the patient's primary contact for health care access, whether by answering routine questions or determining the need for urgent treatment. Additionally, the role may involve many nonclinical responsibilities, such as education of health care team members, interaction with insurance providers, development of clinical protocols, regulatory reporting, participating in performance improvement activities, and research and publication. As a heart transplant coordinator and APRN, I am able to integrate the core competencies of the role in order to provide optimum care to transplant candidates and recipients. One of my primary responsibilities is to provide expert coaching and advice to patients and family members, nursing staff, physicians, other members of the health care team, and members of the community. Education may be formal (in-service or conference presentations, mentoring students or new staff) or informal (“curbside” questions, telephone consultations). In my role I frequently consult with other providers such as surgeons, medical specialists, and mental health providers to be able to ensure optimal care for my patients. Providers who are unfamiliar with transplantation often seek out the assistance of the transplant coordinator to ensure that the plan of care is appropriate, that prescribed medications do not interfere with the immunosuppressive regimen, and that comorbidities and medication side effects are appropriately addressed. Additionally, I have had the opportunity to collaborate with colleagues from other institutions in the publication of specialty core curricula for the International Transplant Nurses Society as well as the American Association of Heart Failure Nurses. Prior to discharge following heart transplantation, I teach patients and their caregivers about the immunosuppressive regimen— including dosing and side effects of medications, signs and symptoms of infection and/or rejection, and health promotion strategies (appropriate immunizations, age-appropriate cancer screening, and heart transplant surveillance). This information is reinforced during clinic visits and during other informal conversations as needed. Successful transplantation requires collaboration among many disciplines. In fact, the Centers for Medicare and Medicaid Services and the United Network for Organ Sharing mandate an interprofessional care model. This interprofessional team consists of surgeons, physicians, nurses, social workers, psychologists, financial counselors, nutritionists, and pharmacists. At different times along the transplant continuum, each patient is reviewed by this team and the plan of care is developed or modified as necessary. The transplant coordinator often leads these team discussions as well as ensures that the appropriate team members have an opportunity to contribute information and expertise. At times these meetings can be contentious because opinions may differ, and the coordinator must guide the team to develop goals for a successful patient outcome. This may also include difficult decisions—ethical dilemmas regarding whether or not to offer heart transplantation. The discussions are difficult because there may not be another treatment option that would provide the patient with improved quality of life. Optimal care of the heart transplant candidate and recipient is both evidence based and guideline directed; thus an understanding of the research process and the ability to translate research findings into clinical practice is essential. As a transplant coordinator I participate in research, both investigator-directed and multiinstitutional protocols, as well as review and critique research manuscripts for publication. In summary, the specialty of organ transplantation continues to grow because of the rising incidence of end-stage organ failure in the population. As an APRN heart transplant coordinator, my clinical role includes both direct and indirect care for and on behalf of a complex patient population. I am afforded the opportunity to enact the core competencies of advanced practice nursing because of the technologic advances in management of heart failure and the influence of these advances on care delivery. The added value of the knowledge of these core competencies enhances care for patients across the transplant continuum. a The author gratefully acknowledges Maureen Flattery, MS, RN, ANP-BC, Richmond, Virginia, for assistance with this exemplar. Forensic Nursing Forensic nursing has emerged as a specialty as a result of the severity of the national public health problems associated with violence. Recognition of the severity of these problems was first addressed in 1985 at the Surgeon General's Workshop on Violence and Public Health. In opening remarks, Dr. C. Everett Koop championed a multidisciplinary approach that addressed the prevention of violence and provision of better care for victims of violence. The severity of the problem was again addressed by the World Health Organization (WHO) in the World Report on Violence and Health (WHO, 2002). As the first comprehensive summary on the global impact of violence, it stated that more than 1.6 million people were dying from violence every year and more were being injured and suffering mental health consequences. More recent information confirms the prominence of this public health problem as a leading cause of mortality, psychologic health effects, and lifelong disability (WHO, 2010). In 1991, the ANA published a position statement on violence as a nursing practice issue and, in 1995, at the request of the International Association of Forensic Nurses (IAFN), they officially recognized forensic nursing as a specialty. In the wake of the ANA position statement, the American College of Nurse-Midwives (in 1995) and the Emergency Nurses Association (in 1996) issued similar statements (Burgess et al., 2004). The scope and standards of forensic nursing practice were initially published in collaboration with the IAFN in 1997 (IAFN/ANA, 1997). These standards were updated in 2009 (IAFN/ANA, 2009) and are in the process of being revised in 2017. Since the 1970s, nurses have been formally recognized providers of health care services to victims of violence. Nurses have volunteered at rape crisis centers and, by the mid-1980s, were widely acknowledged for the expertise they had developed. In addition, nurses also were being recognized for their research competence. This combination of factors opened doors for nurses to collaborate with other health care providers, initiate courses and programs of research on victimology and traumatology, influence legislation and health care policy, and ultimately create a new specialty (Burgess et al., 2004). One organization, the Academy on Violence and Abuse, established in 2005 in response to the challenge issued by the Institute of Medicine (IOM, 2011b; see also Cohn, Salmon, & Stobo, 2002) to educate and train health professionals better about the often unrecognized health effects of violence and abuse, has worked extensively with multidisciplinary experts in violence and abuse prevention (e.g., nurses, dentists, social workers, psychologists, counselors, physicians). Their goal was to develop competencies at the level of the health care system, educational institution, and individuals to be a common starting point for profession-specific criteria regarding the skills, knowledge, and attitudes required for prevention (Ambuel et al., 2011). These efforts broaden the scope of influence of forensic nurses and offer opportunities to advance the specialty. According to the ANA and IAFN, forensic nursing practice is the integration of nursing science, criminal justice, public health, forensic science, and phenomena related to violence and trauma across the life span in providing forensic health care to patients, families, communities, and populations (ANA/IAFN, 2015). Specialization in forensic nursing involves work with perpetrators and victims of interpersonal violence (sexual assault, elder abuse, domestic abuse/violence), death investigations, and legal and ethical issues. Forensic nurses work in concert with a collaborative, multidisciplinary group of professionals such as forensic psychiatric nurses, correctional nurses, emergency nurses, and trauma nurses, as well as a variety of other medical and law enforcement personnel. They may work for specialized hospital units (e.g., forensic psychiatric units), in emergency rooms, in medical examiners' offices, for law enforcement, as legal consultants, and for social services agencies. In addition, in collaboration with school nurses as a consequence of the increasing incidence of school violence, forensic nurses are becoming a significant line of defense for at-risk individuals, groups, agencies, and communities in efforts to reduce school violence (Jones, Waite, & Clements, 2012). Like most stage II specialties, forensic nursing has traditionally been taught outside of formal education programs. Some of the earliest programs were institution-based programs preparing nurses as sexual assault nurse examiners (SANEs). The Commission for Forensic Nursing Certification, the successor to the Forensic Nursing Certification Board, was established in 2012 as an autonomous body to continue the Board's important work in advancing the certification programs of the IAFN. The Commission (IAFN, 2016a) offers three professional credentials: the adult/adolescent (SANE-A®) certification, the pediatric (SANE-P®) certification, and in collaboration with the American Nurses Credentialing Center (ANCC), the portfolio in advanced forensic nursing (AFN-BC). Newer education programs, such as those that prepare sexual assault forensic examiners (SAFEs) or forensic nurse examiners (FNEs), have expanded the scope of forensic nursing practice to include not only sexual assault incidents but also the gathering of forensic evidence in cases of domestic abuse or vehicular accident (IAFN, 2016b). The trend of educating forensic nurses in certificate programs is changing as graduate nursing programs are established; thus forensic nursing is a specialty in transition. Similar to previous efforts to move WOC nursing into graduate nursing education programs (Gray, Ratliff, & Mawyer, 2000), forensic nursing has been taught at the graduate level in a few institutions for several years. Although certificate programs are sometimes the route to preparation, there are now several master's and DNP programs offering this specialty preparation. Commentary: Stage II Forensic nursing provides a different perspective on evolving specialties and is used here to illustrate a stage II practice that may become advanced practice, integrating multiple other specialties such as the family NP, psychiatric and mental health NP and CNS, and women's health NP. In stage II, the specialty becomes more organized and visible. Formal training programs develop, specialty organizations form, and certification moves beyond individual institution-based certificates for completion of training to national certification examinations. All these developments lend strength and credibility to the specialty and its practitioners. Although many forensic nurses are prepared in certificate programs, being a specialty in transition to advanced practice nursing presents some opportunities for this particular specialty to advance to a stage III practice. One of the major challenges in stage II is demonstrating that the specialty is a nursing specialty. There are a number of evolving specialties, such as the previously mentioned advanced diabetes managers and clinical transplant coordinators, whose practitioners include non-nurses and nurses. Clearly, these roles cannot emerge as advanced practice nursing roles without clear distinctions being drawn between non-nursing practice and nursing practice in the specialty. Specialty organizations with members who are non–health care providers, such as NATCO, must face this challenge. In the case of transplantation, for example, recognition of an APRN level of practice or a sanctioning of practice at the APRN level for all specialty providers is evolving. For CTCs or other advanced practice nurses working with transplant candidates or recipients, a mechanism for certifying advanced practice transplant nurses (e.g., through the ITNS) is necessary to recognize nursing's essential role in transplantation, without diminishing the contributions of others who also provide essential care and services. Emerging Advanced Practice Nursing Specialties (Stage III) In the third stage of evolution to advanced practice, a specialty's knowledge base is growing and the scope of practice of nurses with specialty education is expanding. There is growing recognition of the additional knowledge and skills needed for increasingly complex practice in the specialty (Hamric, 2000). Pressures for standardization of education and skills required for specialty practice create incentives to move certificate-level training programs into graduate-level educational settings to increase standardization and raise the status of the specialty to an advanced practice level (Hanson & Hamric, 2003). According to Hanson and Hamric (2003), antecedents to legitimizing advanced practice must be addressed for a given specialty to evolve to advanced levels of practice (see Box 5.1). Two organizations are addressing the issues necessary to legitimize advanced practice in their specialties: the American Association of Nurse Anesthetists (AANA) for interventional pain practice and the Wound, Ostomy and Continence Nurses Society (WOCNS) for WOC nursing. Although these organizations have adopted differing approaches to advancing practice in their respective specialties, in each case the process was unified and proactive and depicts a framework that can guide other specialty organizations as they chart a course to advanced levels of practice. Interventional Pain Practice Millions of individuals suffer from acute or chronic pain every year, and the effects of pain exact a tremendous cost on our country in health care costs, rehabilitation, and lost worker productivity, as well as the emotional and financial burden it places on patients and their families (American Academy of Pain Medicine [AAPM], 2016a). According to the AAPM (2016a), pain affects more Americans than diabetes, heart disease, and cancer combined. Patients' unrelieved chronic pain problems often result in an inability to work and maintain health insurance. According to a recent IOM report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (2011a), pain is a significant public health problem that costs society at least $560 to $635 billion annually, an amount equal to about $2000 for every person living in the United States. Much more needs to be done to meet the challenges of chronic pain management. Because it is underrecognized and undertreated, the overall quality of pain management is and has been unacceptable to millions of patients with chronic pain. Pain management, particularly acute pain management, has been widely embraced in the inpatient and outpatient settings and is provided by a variety of health care professionals, including physicians, PAs, CRNAs, CNSs, and NPs. Interventional pain management, however, has emerged as the need to treat chronic pain has grown. APRNs as interventional pain practitioners face complex and often controversial issues that challenge the legitimacy of this practice. One example is that of CRNAs who, in 1994, expanded their scope of practice to incorporate pain management specifically (AANA Board of Directors, 1994). In the wake of the 2001 Centers for Medicare and Medicaid Services policy, which allowed states to opt out of the reimbursement requirement that a surgeon or anesthesiologist oversee the provision of anesthesia by CRNAs, challenges to this option have been levied in several states to restrict more autonomous practice by these APRNs. It is the position of the American Society of Interventional Pain Physicians (Douglas, 2008; Huddleston, 2016) and the American Society of Anesthesiologists (2009) that interventional pain management is the practice of medicine. Thus actions have been taken in several states to restrict CRNA scope of practice in chronic pain management. Although the outcomes of these actions have been equivocal, in one response by the Federal Trade Commission (FTC) Office of Policy Planning, Bureaus of Economics and Competition, AANA directors replied to an invitation to comment on legislation that would regulate (restrict) providers of interventional pain management services. Insightful comments in this reply addressed the recent IOM report (2011a) that identified a key role for APRNs in improving access to health care and cautioned that restrictions on scope of practice have undermined nurses' ability to provide and improve general and advanced care (IOM, 2011a). Furthermore, the AANA expressed concerns that problems with access to these services may be especially acute for older patients with chronic pain as well as for rural and low-income individuals (AANA, 2011). Because a major component of the legislation addressed consumer protection, legislators were advised to investigate the need for the bill and its potential negative effects on cost, access, and consumer choice and, in the absence of safety concerns, reject the legislation (FTC, 2011). Similar issues have been addressed more recently (FTC, 2012), and concerns related to access and cost were raised—with suggestions to further review the impact of the proposed legislation. Notably, research has demonstrated no increase in adverse outcomes in opt-out or non–opt-out states as a consequence of CRNAs practicing without supervision (Dulisse & Cromwell, 2010). Although these scope of practice issues are unresolved, attention to opportunities for interprofessional collaboration is essential for the pain interventionist role to grow and for APRNs to be recognized as competent providers. To be recognized for their role in chronic pain management, APRNs must be more visible in organizations such as the AAPM and the American Pain Society (APS). Both these organizations welcome providers from multiple disciplines, but nursing is underrepresented. The APS (2016) has reported that approximately 50% of its members are physicians and only 7.4% are nurses. Membership and participation in this organization would improve visibility, recognition, and colleagueship with others providing chronic pain management services. The AAPM (2016a) endorsed the collective benefits that professionals from a variety of disciplines can make to the specialty of pain management. Unlike the APS, the AAPM does offer a credentialing examination (AAPM, 2016b). There are two levels of credentialing—diplomate and fellow— both of which require 2 years of pain management practice prior to examination application. The diplomate credential requires a doctoral degree in a related health care field and the fellow credential requires a master's degree, also in a related health care field. A credentialing review committee determines eligibility to sit for the examination; administration, scoring, psychometric consultation, and analysis of the examination are conducted by an external agency. Although this credential would not be required for specialty practice in chronic pain management, obtaining this certification would ensure a common knowledge base and competencies among all disciplines. Because knowledge and competency have been addressed in challenges to scope of practice, which incorporates chronic pain management, this credential would ensure continuing education and upholding the standards of care in pain management practice. In addition to interdisciplinary certification encompassing core competencies of the specialty, voluntary subspecialty certification for nurse anesthetists in nonsurgical pain management (NSPM-C) through the National Board of Certification and Recertification of Nurse Anesthetists (2016)— initiated in January, 2015—would also establish credibility and promote recognition of practice in the specialty. Wound, Ostomy, and Continence Nursing WOC nursing, a specialty that developed in response to unmet patient needs after fecal or urinary diversion surgery, has evolved significantly since its inception in the 1960s. Historically, laypersons developed the subspecialty, dedicated exclusively to the care of ostomy patients (WOCNS, 1998). As health care changed and new patient needs arose, the original enterostomal therapy role evolved into a nursing specialty whose scope of practice expanded to include wound, skin, and continence care in addition to ostomy care. The WOCNS now recognizes four levels of care providers: WOC advanced practice registered nurse, WOC specialty nurse, foot care nurse, and wound treatment associate (Wound, Ostomy and Continence Nursing Certification Board [WOCNCB], 2016; Wound Treatment Associate Task Force, 2012). Thus the WOCNS and the WOCNCB differentiate among levels of care providers based on certification. The appropriate use of each level of wound care provider is endorsed (WOCNS, 2016). The educational preparation for WOC nurses, which began as clinical training programs based heavily on experiential knowledge about ostomy management, has been provided in postbaccalaureate education programs. Some of these programs have begun to offer graduate-level course work in the specialty. Thus the content has been integrated to a limited extent into graduate curricula of some universities in the United States (Gray et al., 2000; WOCNS, 2016), and over time this trend has continued. Eligibility for advanced practice certification in WOC nursing requires a registered nurse (RN) license and/or a license to practice as an APRN and a master's or higher degree in nursing in an advanced practice role (WOCNCB, 2016). These recent decisions by the WOCNCB to differentiate certification based on education clearly represent progress in addressing the added value of APRNs in this specialty. This is a critical decision point for this stage III specialty. Similar to the work done by the International Society of Nurses in Genetics (ISONG; see “Genetics Advanced Practice Nursing” later), who established levels of genetics knowledge, practice, and certification, WOC nursing has advocated for APRNs as having unique characteristics and contributions to make. These contributions reflect advanced practice core competencies obtained in graduate nursing education in addition to competencies attained in a specialty program aimed at preparing WOC nurses. The advanced practice certification builds on the entry-level certification and offers an incentive to entry-level WOC nurses to complete graduate nursing education as an APRN; it also further legitimizes the advanced practice of WOC nursing. APRNs in the specialty may also wish to pursue additional recognition for advanced practice competency. Some nurses with graduate education in WOC nursing may seek certification as a wound management specialist (certified wound specialist [CWS]), a certification awarded to qualified clinicians through the American Board of Wound Management (2016) by the American Academy of Wound Management, a multidisciplinary organization; CNSs or NPs may seek certification as a urologic specialist by the certification board of the Society of Urologic Nurses and Associates (Certification Board for Urologic Nurses and Associates, 2016). In particular, the CWS certification recognizes a shared clinical knowledge base among professionals providing care to patients with complex wounds and may foster collaborative relationships that would further advance this specialty. Commentary: Stage III The stage III specialties discussed here are characterized by a growing knowledge base and an expanded scope of practice. For example, APRNs practicing as pain interventionists, most notably CRNAs, have expanded their scope of practice to incorporate advanced diagnostic and treatment knowledge and skills to make pain intervention more accessible. As a consequence, questions regarding their qualifications to provide these services have led to legal challenges. Some APRNs in this specialty, in addition to advanced practice certification, have responded to these challenges by seeking credentialing by multidisciplinary specialty organizations, a strategy that lends credibility to their practice. This barrier to evolution to a stage IV specialty is likely to be overcome as more APRNs transition to this specialty and demonstrate practice competencies. Exemplar 5.3 depicts an interprofessional collaborative practice and the CRNA's knowledge and expertise to deliver patient-centered, evidence-based care. To increase awareness of what can safely and competently be provided by CRNAs in pain management practice, these APRNs need to increase their visibility through membership in pain management specialty organizations and credentialing as pain practitioners, better positioning the specialty to emerge as a stage IV role. Exemplar 5.3 Interventional Pain Practicea The inception of PainCare in 1992 marked the beginning of interprofessional interventional pain management in the northern New England region of Maine, New Hampshire, and Vermont. This organization began to address a growing need for management of untreated chronic pain in underserved and remote regions of the northeast. Five certified registered nurse anesthetists (CRNAs) work as fully autonomous clinicians within this highly specialized practice setting; they provide comprehensive pain management services to those suffering from a wide variety of chronic pain conditions, many of whom have suffered for years without relief as the result of lack of access to specialized pain care. In our pain management facility, the process of treating chronic painful conditions begins with meeting the patient during an initial office visit. The referral base for our patients includes specialty physicians (neurosurgical and orthopedic surgeons), primary care physicians, and nurse practitioners. This initial consultation entails taking a comprehensive and detailed medical and surgical history and performing a focused physical examination. At the conclusion of the initial office visit, we order the appropriate laboratory and imaging studies based on best evidence. Diagnostic studies may include electromyelography, ultrasound scanning, angiography, and/or bone scans. Because pain management is often interdisciplinary, we may make referrals to specialists such as neurologists, physiatrists, endocrinologists, oncologists, or orthopedic surgeons. One of our roles as CRNA pain practitioners is to assimilate the findings from the patient's detailed medical history, extensively focused physical examination, and diagnostic testing. This is essential in identifying the causative pain generator and engaging an accurate treatment plan. Chronic pain can be difficult to treat and standard, conservative, and surgical treatments may prove unsuccessful. Prior surgical interventions often contribute to a patient's suffering. Furthermore, most patients who seek care at the pain center are currently taking prescription narcotics. Large doses of narcotics contribute significantly to tolerance issues. Side effects and systemic complications related to these potent medications are evident during the initial consultation with the patient. In these cases, pain relief is no longer forthcoming. The patient in chronic pain may experience many years of treatment and mistreatment prior to seeking care at our pain center. Management of chronic pain requires a multimodal treatment plan. Once the process of patient counseling is initiated, it is our responsibility to initiate the discussion about realistic pain management expectations through patient education. Educating patients with regard to their pathology and treatment plan helps them gain a sense of control and understanding and places them as the central change agent. These chronic pain management patients are expected to attend all scheduled appointments and be active participants in the treatment plan. The patient must know that management of his or her pain will take time and that improving quality of life is a major goal of treatment. As pain managers, we regularly make referrals as an integral component of clinical practice. Referrals may be made for one or a combination of the following: physical therapy, occupational therapy, chiropractic sessions, acupuncture, craniosacral therapy, and/or message therapy. We may refer obese or diabetic patients to nutritionists for counseling if it is thought that these conditions may be contributing to their pain. Additionally, therapeutic devices such as lumbar, thoracic, and cervical support braces, transcutaneous electrical nerve stimulation (TENS) units, or orthotics may be incorporated into the treatment plan for spine and extremity pain. Smoking cessation, biofeedback, and hypnosis may also play a role in effective pain management treatment plans. Frequently, we see patients with coexisting psychiatric issues such as anxiety, depression, bipolar disorder, substance abuse, and posttraumatic stress disorder. Psychiatric professionals provide treatment and counseling as an essential part of an effective treatment plan. If a question of substance abuse arises, referrals for substance abuse evaluation and treatment are initiated. Our practice environment includes a comprehensive substance abuse program that plays an integral role in our interprofessional treatment facility. An essential part of the practice includes medication management. Prescribing and selecting from a wide array of medications with various mechanisms of action contribute to the goal of relieving the patient's suffering. For example, opioids are prescribed for severe persistent pain and offer significant relief when other pharmacologic agents are not effective. On the other hand, more invasive procedures such as interventional injections may be used, which directly address causative pain generators. For example, during any given week, a pain manager may administer 40 to 50 cervical, thoracic, and lumbar epidural steroid injections; transforaminal injections; facet joint and medial branch nerve blocks to the cervical, thoracic, and lumbar regions; stellate ganglion blocks; lumbar sympathetic blocks; hypogastric plexus blocks; occipital nerve blocks; intra-articular joint injections; and peripheral nerve blocks. To improve accuracy and maximize safety, all invasive procedures are performed under direct fluoroscopic guidance to ensure accurate needle placement. Every interventional injectionist must be an expert with regard to imaging analysis and interpretation. CRNAs involved in pain management recognize the potential for serious and sometimes fatal complications related to these procedures. Profound and lasting pain relief, and quality and safety in practice, mandate that the pain practitioner be well trained in invasive and noninvasive pain management techniques as well as radiation safety. Prior to independent practice, I was trained under the direct supervision of an anesthesiologist–interventional pain physician. Successful completion of interventional injection procedures under direct supervision and documentation of hundreds of procedures was required to be involved in this type of advanced practice. My clinical privileges were granted on written request and approved by the medical director and clinical board members. In 2009, I earned a Doctor of Nurse Anesthesia Practice (DNAP) degree that has further prepared me to incorporate best evidence into my clinical practice, contribute to nurse anesthesia scholarship, and assume various leadership roles. Additionally, I am certified with the American Academy of Pain Management as a Diplomate. This certification requires a doctoral degree, a 2-year practice in a pain management setting, recommendations from colleagues, and successful completion of a written certification examination. Additional study and training include participation in interventional pain cadaver conferences and completion of continuing education via the American Academy of Pain Management and the International Association for the Study of Pain. The nurse anesthesia subspecialty of pain management is evolving in many exciting and innovative ways. For example, Excel Anesthesia and Pain Management Associates (EAPMA) is a group of CRNAs who provide training for university-based student registered nurse anesthetists (SRNAs) and other CRNA populations. Under Medicare guidelines, EAPMA CRNAs are able to bill for direct supervision and training of resident SRNAs. This unique billing arrangement is expected to enhance and expand CRNA pain practice. One US university has developed a specialized pain track for nurse anesthetists earning a clinical doctoral degree. Graduates of this program will qualify to sit for the AAPM certification examination. Members of EAPMA are also developing a separate certification examination for subspecialty pain management practice. I believe the training and certification of CRNA pain managers is at an exciting turning point and will continue to establish itself. These well-trained and qualified pain practitioners will be a new generation of clinicians able to provide access to pain management services to underserved, critical access, and remote regions of the United States in which these services are currently unavailable. With over 400 patients under my care, I function autonomously in the role of pain manager. It is a true joy to practice in a setting where I am respected as an equal among interventional pain physicians, physiatrists, anesthesiologists, nurse practitioners, physician assistants, and primary care physicians. Almost all patients make significant progress in managing their chronic pain using an interprofessional treatment plan. Patients too often arrive at a pain center misunderstood and misdiagnosed, with their complaints deemed questionable. My role as pain manager at our facility is vital and serves an important public health function. The most gratifying part of my work is to witness patients who obtain pain relief for the first time in their lives. a The author gratefully acknowledges Russell Plewinski, DNAP, CRNA, DAAPM, Somersworth, New Hampshire, and Suzanne M. Wright, PhD, CRNA, Richmond, Virginia, for assistance with this exemplar. WOC nurses have clearly differentiated basic professional practice from advanced practice in the specialty. However, attention to several issues is still necessary for the specialty to emerge fully at the advanced (stage IV) level (Box 5.2). For example, most WOC nurses are educated in certification programs. Only two accredited programs offer graduate credit for coursework toward clinical master's or doctoral degrees (DNP) (WOCNCB, 2016). Preparation in graduate or post-master's programs would standardize education and advance practice in the specialty. There are levels of practice in place that differentiate advanced practice nursing through their certification process. Thus this specialty is poised to emerge as a stage IV specialty as a result of efforts clarifying certification and credentialing requirements and the initiation of advanced practice certification. Box 5.2 Questions to Address in Charting Specialty Evolution • Are advanced practice nursing competencies required to enact specialty practice fully, or are they an added value? • What are the distinct advanced practice nursing roles within the specialty? • How can the organization best recognize and value existing providers while moving to new expectations? • How should certification and educational expectations be structured, especially if differentiating practice between nonAPRNs and APRNs continues within the specialty? • How should subspecialty certification within the context of advanced practice nursing regulation be addressed? • How can the centrality of direct clinical practice be maintained? Established Advanced Practice Nursing Roles (Stage IV) The fourth stage in the evolution of specialty practice to advanced practice is characterized by mature specialties. APRNs practicing in these specialties are experts in the specialty, secure in understanding the unique contributions that they make in the direct care of patients. However, they embrace the notion that aspects of their practice are shared by experts from other disciplines essential to the care of their patients. Because of its origins in interprofessional practice, the advanced diabetes manager characterizes an established APRN role. APRNs in genetics have overcome obstacles to interdisciplinary practice through the development of interprofessional collaborative relationships and have also emerged as a stage IV APRN role. Advanced Diabetes Manager The rising incidence of diabetes mellitus has created new opportunities for APRNs. Advances in the science and technology of diabetes care and findings from two clinical research trials have redefined the roles of health care providers in diabetes care. Two classic studies, the Diabetes Control and Complications Trial (Diabetes Control and Complications Trial Research Group et al., 1993) and the United Kingdom Prospective Diabetes Study (United Kingdom Prospective Diabetes Study Group, 1998), have demonstrated the value of interprofessional teams consisting of dietitians, nurses, and pharmacists in the clinical management of those with diabetes mellitus. Before the results of these clinical trials were released, however, the American Association of Diabetes Educators (AADE, 2004) published multidisciplinary scope and standards of practice guidelines, which were revised in 2005 (Martin et al., 2005). An advanced practice task force was established in 1993, and the dialogue among the three major disciplines constituting the membership of the association—nurses, dietitians, and pharmacists—and their credentialing bodies was initiated (Hentzen, 1994; Tobin, 2000). These collaborative efforts resulted in a definition of advanced practice in diabetes as the highest of various levels of practice used along the full continuum of diabetes care (Hentzen, 1994; Tobin, 2000). These levels are identified as the certified diabetes educator (CDE) and the boardcertified advanced diabetes manager (BC-ADM) (Martin et al., 2005). The CDE is a health care provider who meets educational and practice requirements, successfully completes the certification examination for diabetes educators, and is credentialed by the National Certification Board for Diabetes Educators. The CDE can provide the following: case management; diabetes education program development, coordination, and implementation; and referral to advanced practitioners, other health care team members, or community resources. The BC-ADM, launched in 2000 as a result of unprecedented multiorganizational collaboration and initially credentialed by the ANCC, has been credentialed by the AADE since 2011. This advanced practice credential focuses on the management of diabetes, including prescribing medications, rather than on diabetes education; thus this credential distinguishes between two sets of skills (Daly, Kulkarni, & Boucher, 2001; Valentine, Kulkarni, & Hinnen, 2003). This level of credentialing is designed for licensed health care professionals, including registered dietitians, RNs, and registered pharmacists, as well as—more recently—PAs and physicians who hold graduate/advanced degrees and have recent clinical diabetes management experiences after they have been licensed. Currently, RNs make up the largest proportion of BC-ADMs (56.7%), followed by pharmacists (18.7%) and dietitians (9.5%) (J. Ricketts-Byrne, personal communication, 2016). Credentialing as a CDE is not required to take the advanced management examination. Notably, the BC-ADM designation is unique. Although each discipline eligible for certification takes a different examination (Valentine et al., 2003), it was the first multidisciplinary approach to the certification of nurses, dietitians, and pharmacists ever developed by the ANCC (Daly et al., 2001; Valentine et al., 2003). The fact that the ANCC agreed with the AADE's request to support the advanced-level examination for disciplines other than nursing to promote team collaboration and improve quality of care for individuals with diabetes represented the emergence of a new model of collaboration among practitioners who formerly may have competed for recognition by patient and consumer groups. The potential benefits of multidisciplinary certification include increased credibility with colleagues, patients and consumers, employers, and other health care professionals as a result of a shared knowledge base; differentiation of these providers as having advanced-level expertise in diabetes management; greater autonomy in the delivery of care and services; and improved reimbursement (Daly et al., 2001). In this multidisciplinary model, APRNs fill a niche in the care of these patients that facilitates self-care and achievement of treatment goals. Nurses constitute the largest group of health care professionals who deliver care to individuals with diabetes mellitus across the life span and in a variety of settings; therefore, graduate-level preparation for APRNs in diabetes management, consistent with American Diabetes Association standards, helps to fulfill the growing need for care providers in acute and primary care settings. Genetics Advanced Practice Nursing Mapping the human genome and the relevance of the Human Genome Project to health and disease have been revolutionizing the provision of genetic services specifically and health care generally. New genetic discoveries have made available an increasing number of genetic technologies for carrier, prenatal, diagnostic, and presymptomatic testing for genetic conditions. These discoveries are creating changes in the delivery of genetic services, the most immediate being the integration of genetics into the prevention and treatment, for example, of cardiovascular disease (Arnett et al., 2007; Santos et al., 2016), obesity (Walley, Blakemore, & Froguel, 2006; Yang, Kelly, & He, 2007), and cancer (Balmain, Gray, & Ponder, 2003; Karakasis, Burnier, Bowering, Oza, & Lheureux, 2016). Although brought to the forefront of public awareness by the mapping of the human genome, genetic services initially emerged out of a need for professionals who could provide genetic information, education, and support to patients and families with current and future genetic health concerns. Genetics experts in academic, medical, public health, and community-based settings have traditionally provided these services. In each setting, genetics professionals, including medical geneticists, genetics counselors, and genetics APRNs, provide genetic services to patients and families. Working with other team members, genetics specialists obtain and interpret complex family history information, evaluate and diagnose genetic conditions, interpret and discuss complicated genetic test results, support patients throughout the genetic counseling process, and offer resources for additional individual and family support. Personalized medicine, an approach to care in which an individual's genomic information is used to tailor interventions to maximize health outcomes, is rapidly becoming a reality for several health conditions as a result of increased understanding of some of the most common health conditions (Feero & Guttmacher, 2014). According to ISONG, the scope of genetics nursing practice is basic and advanced. At the basic level, genetics nurses are prepared to perform assessments to identify risk factors, plan care, provide interventions such as information, and evaluate for referral to genetic services. At the advanced level, master's-prepared nurses provide genetic counseling, case management, consultation, and evaluation of patients, families, resources, and/or programs (ANA/ISONG, 2016). Two levels of practice and recognition, which correspond to the scope of genetics nursing practice, currently exist: the genetics clinical nurse (GCN) and the advanced genetics nurse credential (AGN-BC). The credentials conferred by the ANCC mandate that specific educational, practice, and professional service requirements are met. The process is accomplished using a portfolio review. Eligibility for the AGN-BC certification requires the following: (1) hold a current, active RN license in a state or territory of the United States or hold the professional, legally recognized equivalent in another country; (2) practice the equivalent of at least 2 years full time as an RN; (3) have a graduate degree (master's, postgraduate certificate, or doctoral degree) in nursing; (4) have a minimum of 1500 practice hours in the specialty area of advanced genetics nursing in the past 3 years; and (5) have completed a minimum of 30 continuing education hours in genetics/genomics applicable to nursing within the last 3 years (ANCC, 2016). Currently, there are 82 nurses who hold AGN-BC certification (A. S. Kerber, personal communication, 2016). Only four programs offer graduate-level genetic programs for nurses. Currently, educational preparation for APRNs occurs in master's programs in nursing. Although an increased focus on genetics has been occurring in graduate nursing programs as a result of recent revisions in the Essentials of Master's Education in Nursing (American Association of Colleges of Nursing, 2011), genetic content is usually obtained later in postbaccalaureate education programs or through continuing education courses. Regardless of the type of program or course, the course content must reflect the following: information in human genetics; molecular and biochemical genetics; ethical, legal, and social issues in genetics; genetic variations in populations; and clinical application of genetics, including genetic counseling to meet requirements for certification. Expectations for evidence-based practice, an advanced practice competency, which has the potential to transform health care because of integration of genetic knowledge, requires the knowledge acquired in graduate nursing education. In addition, the ethical decision-making skills of APRNs are important to this specialty. Because graduate nursing education preparation required for the AGN-BC credential places these nurses at the same level as other genetic services providers, such as genetics counselors, professional diversity and interprofessional collaboration are fostered. The American Board of Genetic Counseling certifies some nurses; however, this avenue is not open to nurses unless they complete graduate education and clinical practice requirements in genetics medicine, human genetics, and/or genetic counseling. Nurses who wish to pursue graduate education solely in nursing are not eligible for this certification. Because the scope of practice for the advanced practice nurse in genetics is much broader than that of a genetics counselor, differentiation based on credentials is appropriate. In addition to counseling, the advanced practice nurse in genetics diagnoses and treats patients with a variety of clinical disorders (e.g., birth defects, chromosomal abnormalities, genetic disorders presenting in newborn, child, and adult muscular disorders, and intrauterine teratogen exposure) and inherited conditions. Because of the complexity of care required, collaboration among these professionals is necessary for appropriate genetics services delivery. Toward this end, the National Society of Genetic Counselors and ISONG jointly developed a position statement advocating a multidisciplinary collaborative approach to enhance the quality of genetic services and care (ISONG, 2006). These efforts by the ISONG have positioned the specialty to transition to a stage IV specialty as a result of collaborative efforts with genetics counselors who are master's prepared for their role (Exemplar 5.4). Exemplar 5.4 Insights From Leaders in the Genetics Specialty a In 1976, the Genetic Diseases Act was passed by Congress and the Genetic Diseases Services Branch of the Office of Maternal Child Health, Health Services Administration, Department of Health and Human Services, was established. At that time, a small and academically diverse group of nurses was working with genetic programs in tertiary health care settings. They tended to come from practice backgrounds in pediatrics or obstetrics, which made sense because genetic services at that time were centered primarily on the delivery of prenatal diagnostic procedures and the evaluation of the dysmorphic child or the child with developmental delays. A relatively small number of master's-prepared genetics counselors also were working in similar settings. In the 1980s, however, medical geneticists started to employ or collaborate with nurses rather than counselors for a variety of reasons, including the limited number of counselors available and the broader scope of practice of nurses. Differing perspectives emerged regarding basic requirements for certification and the appropriate credentialing body for awarding certification. Genetics counselors are required to have a degree from an approved master of science in genetic counseling program and are credentialed through the American Board of Medical Genetics (ABMG). In contrast, nurses advocated for a professional nursing organization as an appropriate credentialing body and graduate education in nursing as an acceptable educational route. The number of genetics counselors increased faster than the number of genetics nurses in the 1980s. This led to the education meetings of the National Society of Genetic Counselors (NSGC) becoming focused on the learning needs of genetics counselors, not consistently and sufficiently addressing the issues that confronted genetics nurses. After the initial NSGC educational meetings, a bond was formed among those nurses working in genetics and monies were found to form the Genetics Nursing Network. In 1987, there was significant discussion among the members of the network regarding the benefits of establishing a formal professional organization for genetics nurses. The lack of a professional group and the inability to obtain certification that would be recognized by the nursing profession led to the development of the International Society of Nurses in Genetics (ISONG). Membership in the organization continued to grow but the issue of certification remained unresolved. Nurses working in genetics had academic preparation ranging from diplomas to doctoral degrees. Some were already certified as genetics counselors and others were certified as nurse practitioners in their specialty area. After significant discussion by the membership of the ISONG, it was thought that the core knowledge required by genetics nurses was broader, but there was also the issue of recognition of a credential provided by a non-nursing organization being accepted by the nursing community. Also, it was understood that at that time there were not enough nurses to sit for a written examination to provide for test item validation. Therefore the Genetic Nursing Credentialing Commission was established to investigate alternatives that would address these issues. After extensive work, the Commission announced the establishment of the advanced practice nurse in genetics (APNG) credential and awarded the first credentials (by portfolio) in 2001. Currently the advanced genetics nurse credential (AGN-BC) is provided by the American Nurses Credentialing Center (2016). As genetic knowledge has continued to develop, genetics has become an integral part of the education and clinical practice of all nurses. The ISONG has worked with the National Coalition for Health Professional Education in Genetics to develop competencies for health care professionals at the generalist and specialty levels and has collaborated with the American Nurses Association (2008) to publish these competencies, curricula guidelines, and outcome indicators specific to nurses. ISONG continues to grow and develop to meet the needs of nurses who are at any point on the novice to expert continuum and who focus on clinical practice, professional or consumer education, or research. a The author gratefully acknowledges Shirley Jones, PhD, RN, Louisville, Kentucky, and Judith Lewis, PhD, RN, Richmond, Virginia, for their assistance with this exemplar. Commentary: Stage IV Caring for persons with diabetes has become complex, requiring the expertise and efforts of interprofessional teams. Because the nature of caring for patients with diabetes has historically required interdisciplinary collaboration, health care providers from these disciplines are secure in understanding the unique contributions that they make in patient management. They are experts—secure in their individual and shared clinical knowledge base—and embrace the challenges and opportunities inherent in interprofessional collaboration. This model of collaboration is somewhat unique and has been expertly developed by leaders in the AADE. The trajectory of change that was initiated in the early 1990s exemplifies the natural maturation of the specialty resulting from deliberate logical planning to strengthen the education and broaden the scope of practice of practitioners in this specialty. Similarly, and strategically, ISONG has made tremendous progress in defining roles for health care providers, including APRNs who are experts in genetics, fostering a collaborative relationship with genetic counselors and differentiating levels of practice within interprofessional teams. Conclusion As can be seen from Chapter 1, the evolution of specialties in nursing has a long and rich history that continues in the present. The progress made by members of specialty organizations that have evolved their specialties to advanced levels of practice (stages III and IV) can serve as examples for others that are struggling to evolve (stage II) or are newly emerging (stage I). This chapter has examined each of these stages in the context of selected specialty groups and the evolving and innovative roles that characterize progression toward advanced practice nursing. Clearly, the ability to be deliberate in efforts to evolve the specialty speeds progress, as demonstrated by organizations such as the WOCN, AADE, and ISONG. Some specialties have evolved haphazardly. Others may not evolve into advanced practice nursing; without commitment from the nursing community and attention to the issues noted in Boxes 5.1 and 5.2, the move toward advanced practice nursing may be an unrealistic goal. It is important to recognize that progression to advanced levels of practice is neither inevitable nor necessary. For example, staff development educators are a respected specialty group within the nursing profession, yet their competencies are not consistent with those of advanced practice nursing (Hanson & Hamric, 2003). As specialties move through the stages described here, one important question for the specialty's leadership is whether the specialty is best advanced by deliberate evolution to the advanced level of practice, development of differentiated levels of practice with distinct expectations and certifications, or continued development as a specialty (see Box 5.2). In these decisions, it is critically important to affirm the roles and value of all providers in the specialty, even as differentiation occurs for advancement and strengthening of specialty roles. Concern over whether a specialty role is a shared nursing role (versus exclusively a nursing role) is an issue that will need to be examined in particular specialties. In the history of nursing, some roles have been characterized as sharing attributes with other types of health care providers. For example, some psychiatric CNSs attained their credentials to practice as licensed professional counselors. Other health care providers (e.g., counselors, psychologists) also receive this same credential, despite educational differences. Failure to acknowledge the value of multidisciplinary teams, shared knowledge, and overlapping expertise may limit opportunities for APRNs in the current health care environment and impede the advancement of specialties in the discipline. As a profession, nursing must embrace the notion that some roles are not exclusively nursing and must endorse differentiated practice models. At the same time, the profession must define the advanced level of practice within the interprofessional model. This is critical for regulatory purposes, standardization of APRN competencies in the practice, and recognition by the public and insurers. In addition to the AADE, other specialty organizations (Table 5.2) certify health care providers who share a common knowledge base. These organizations are models of collaboration that communicate to consumers, other providers, third-party payers, and other stakeholders that there are national standards in the specialty that are upheld by these specialty care providers. These multidisciplinary collaborative models represent a trend in health care that has given rise to a fourth stage in the evolution of advanced practice nursing. This stage is characterized by APRNs who are mature, expert practitioners in a specialty, secure in understanding the unique contributions that they make in the direct care of patients, yet embracing the notion that some aspects of their practice are shared by experts from other disciplines essential to the care of their patients. TABLE 5.2 Specialty Organizations Offering Advanced-Level Certification Specialty Organization Credentialing Organization; Credential Awarded American Academy of HIV Medicinea American Academy of HIV Medicine; HIV Specialist Graduate Nursing Education Required? Implied (must be licensed as an NP) Academy of Integrative Pain Academy of Integrative Pain Management; Management (formerly American APMP Academy of Pain Management)a Yes American Board of Wound Managementa Yes (for diplomate or fellow status) American Association of CriticalCare Nurses American Board of Wound Management; CWS AACN Certification Corporation; CCNS,b ACNPC,b ACNPC-AG, ACCNS-AG, ACCNS-P, ACCNS-N Yes American Association of Diabetes Educatorsa American Association of Diabetes Educators; BC-ADM No (master's in nursing or related field) Association of Nurses in AIDS Care HIV/AIDS Nursing Certification Board; AACRN Yes Hospice and Palliative Nurses Association Hospice and Palliative Credentialing Center; ACHPN Yes International Society of Nurses in Genetics American Nurses Credentialing Center; AGN-BC Yes International Nurses Society on Addictions Addictions Nursing Certification Board; CARN-AP No (master's in nursing or related field) Oncology Nursing Society Oncology Nursing Certification Corporation; AOCNS, AOCNP Yes Wound, Ostomy and Continence Nursing Society Wound, Ostomy and Continence Nursing Certification Board; CWOCN-AP, CWCN-AP, COCN-AP, CCCN-AP Yes Society of Urologic Nurses and Associates Certification Board for Urologic Nurses and Associates; CUNP Yes (must already be NP) a Multidisciplinary membership. b To conform with requirements of the Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008), the CCNS and ACNPC exams are no longer offered, and these credentials are available now only as renewals. AACRN, Advanced AIDS Certification Registered Nurse; ACCNS-AG, Acute Care Clinical Nurse Specialist–Adult-Gerontology; ACCNS-N, Acute Care Clinical Nurse Specialist– Neonatal; ACCNS-P, Acute Care Clinical Nurse Specialist–Pediatrics; ACHPN, Advanced Certified Hospice and Palliative Nurse; ACNPC, Acute Care Nurse Practitioner Certification; ACNPC-AG, Acute Care Nurse Practitioner–Adult-Gerontology; AOCNP, Advanced Oncology Certified Nurse Practitioner; AOCNS, Advanced Oncology Certified Clinical Nurse Specialist; AGN-BC, Advanced Genetics Nursing-Board Certified; APMP, Advanced Pain Management Practitioner; BC-ADM, Board Certified-Advanced Diabetes Management; CARN-AP, Certified Addictions Registered Nurse–Advanced Practice; CCCN-AP, Certified Continence Care Nurse–Advanced Practice; CCNS, Critical Care Clinical Nurse Specialist; COCN-AP, Certified Ostomy Care Nurse–Advanced Practice; CUNP, Certified Urologic Nurse Practitioner; CWCNAP, Certified Wound Care Nurse–Advanced Practice; CWOCN-AP, Certified Wound Ostomy Continence Nurse–Advanced Practice; CWS, Certified Wound Specialist. The proliferation of role titles seen in evolving specialties requires special attention as APRNs begin practicing in the specialty. For example, within the transplant specialty, role titles such as clinical transplant coordinator, transplant coordinator, transplant nurse, transplant NP, and transplant CNS have been used in practice settings. The advanced practice role titles of CNS, NP, CRNA, and certified nurse-midwife need to be consistently applied to APRNs who are practicing in particular specialties to decrease role confusion. In addition, this consistency is important for promoting the recognition of advanced practice nursing within evolving specialties and the profession as a whole. For specialties that develop nonadvanced and advanced levels of practice, consistent titles are necessary to avoid confusion among providers and patients. This is an extraordinarily interesting time in the history of the nursing profession. Opportunities and challenges for advanced practice nursing abound. What will the history books say about this period in the evolution and expansion of the nursing profession? As Hamric (2000) wrote in addressing the WOC specialty group, “[Our] hope is that they will say [we] clearly saw patients' needs and developed [our] skills to meet those needs; that [we] grasped the role opportunities that were possible and created new ones; and, most importantly, that [we] moved forward together” (p. 47). Key Summary Points ■ Professional and specialty organizations have been the driving force behind efforts to recognize and differentiate advanced practice nursing in a specialty or subspecialty. ■ Although interprofessional practice characterizes advanced practice in all stages of evolution, mature specialties are characterized by experts in the specialty or subspecialty and a shared knowledge base with other health care professionals. 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Epidemiologic Reviews. 2007;29:49–61. CHAPTER 6 International Development of Advanced Practice Nursing Denise Bryant-Lukosius, Frances Kam Yuet Wong “What you do makes a difference, and you have to decide what kind of difference you want to make.” —Jane Goodall CHAPTER CONTENTS Advanced Practice Nursing Roles Within a Global Health Care Context, 129 Defining Advanced Practice Nursing, 129 Global Deployment, 130 Types of Advanced Practice Nursing Roles, 130 New Frontiers and Future Role Expansion, 133 Facilitating the Introduction and Integration of Advanced Practice Nursing Roles, 135 Pan-Approaches and Collaboration, 135 Funding and Reimbursement Arrangements, 138 Systematic Approaches to Role Planning, 139 Use and Generation of Evidence, 140 Next Steps in the Global Evolution of Advanced Practice Nursing Roles, 140 Conclusion, 140 Key Summary Points, 141 The authors gratefully acknowledge Joyce Pulcini for the previous edition of this chapter. Internationally, advanced practice nursing (APN) roles are on the threshold of new development and expansion that will include the first-time introduction of the roles in some countries and improved health systems integration in countries where roles are established. This chapter examines the current state, areas of progress, and new frontiers for APN role development within the global health care context. Evidence-based factors for facilitating the introduction of APN roles are explored and the next steps for supporting the global development of the roles are identified. Advanced Practice Nursing Roles Within a Global Health Care Context Defining Advanced Practice Nursing There is international agreement that clinical practice involving the direct care of patients and families, groups, communities, or populations is a defining feature of APN roles and that these roles require an expanded range of competencies that include, but are in addition to, those for the basic practice of a registered nurse (Dowling, Beauchesne, Farrelly, & Murphy, 2013; Hamric, 2014; International Council of Nurses [ICN], 2008). The integration of clinical practice with competencies related to education, professional and organizational leadership, evidence-based practice, and research is what makes the roles advanced. However, just as the nursing profession is at different stages of development in countries around the world, so too is the development of APN roles. Reflecting the evolving nature of APN roles globally, the ICN (2008) broadly defines the nurse practitioner/advanced practice nursea as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level. (p. 7) Common features of APN roles include advanced education from an accredited program; formal licensure, registration, certification, and credentialing; integration of research, education, and management (leadership) with advanced clinical competencies; and regulatory mechanisms for autonomous and expanded scope of practice (ICN, 2016b). These features are consistent with the regulatory framework for the advanced practice registered nurse (APRN) in the United States related to licensure, accreditation, certification and education (LACE) (APRN Joint Dialogue Group, 2008). However, LACE features have more detailed role requirements rather than recommendations, as suggested by the ICN (2008, 2016b). Global Deployment Strong global demand for APN roles has been evident since 2001 and the launch of the ICN's International Nurse Practitioner/APN Network (INP/APNN) (Bryant-Lukosius & Martin-Misener, 2016). Internationally, few human resource systems are in place to monitor APN role deployment, and at country levels there are absent or inconsistent methods for identifying nurses in these roles. As such, the number of countries with APN roles is unknown but may range from 26 (Heale & Rieck-Buckley, 2015) to 68 (Roodbol, 2004). APN roles are found mainly in high-income countries, of which Canada, the United Kingdom, and the United States have the most established roles with decades of experience (see Chapter 1). In the last decade, APN roles have spread to other high-income countries such as South Africa and Singapore (Ayre & Bee, 2014; South African Nursing Council, 2012) and upper middle income countries like Jordan (Zahran, Curtis, Lloyd-Jones, & Blackett, 2012). There are few reports of APN roles in low- or middle-income countries. In the last 6 years, interest in APN roles has intensified within the context of World Health Organization (WHO, 2010) strategic directions to meet 2015 Millennium Development Goals for improving global health. It was recognized that national health care systems could be improved by enhancing nursing roles to address provider shortages, overcome inequities through universal health coverage, and improve care quality. Recommendations included establishing postbasic continuing nursing education programs to support advanced clinical practice (WHO, 2010); introducing specialized and APN roles to meet population health and health service needs, especially for primary health care (WHO, 2012); and developing career pathways for APN roles (WHO, 2015c). Types of Advanced Practice Nursing Roles In the United States, the regulatory framework for the APRN is specific to four certified roles: the nurse anesthetist (NA), nursemidwife (NM), clinical nurse specialist (CNS), and nurse practitioner (NP) (APRN Joint Dialogue Group, 2008). The introduction of these longstanding roles varies in other countries, but internationally the CNS and NP roles are the most common types of APN roles (Delamaire & Lafortune, 2010; Heale & Rieck-Buckley, 2015). In the last 20 years, the nurse consultant (NC) has emerged as a new type of APN role (Baldwin et al., 2013). Nurse-Midwife Midwifery is one of the oldest health professions, dating back to the Stone Age (Barnawi, Richter, & Habib, 2013). As the profession evolved, a variety of sociocultural factors influenced the development of nursing and non-nursing midwifery roles, including NMs (have nursing and midwifery education), midwives (have midwifery but no nursing education), nurses, traditional birthing attendants, and generalist and specialist physicians. The International Confederation of Midwives (ICM, 2010) has developed competencies for basic midwifery practice that apply, but are not specific to, advanced roles. The education of NMs is variable, ranging from 2 to 6 years, with about half completing at least 4 years of training (United Nations Population Fund [UNFPA], 2014). This suggests that not all NMs have a master's degree as recommended by the ICN (2008) for APN roles. NMs who meet the ICM (2010) competencies have a scope of practice that includes prevention, health promotion, detecting complications, accessing medical care, and providing emergency measures within a primary health care framework. They work in varied settings, including the home, community, hospital, clinics, birthing centers, or health units. Improving maternal-child health by expanding midwifery services, and in particular increasing the number of NMs and midwives, is a global priority (UNFPA, 2011). Major drivers are high maternal and infant morbidity and mortality rates, especially in low- and middleincome countries, as well as the increasing costs of medicalized care and growing use of unnecessary and expensive interventions such as cesarean sections (Renfrew et al., 2014). The importance of NMs and midwives for improving maternal-child care cannot be overstated. A report has shown that NMs and midwives with the appropriate education and who are regulated to meet ICM competencies for practice can deliver 87% of midwifery care (UNFPA, 2014). Since 2010, collaboration between the United Nations, the ICM, and the WHO led to a series of consensus meetings with agreement on strategic priorities and reporting on key indicators (Day-Stirk et al., 2014). As a result, there are more global workforce data on NMs compared to other types of APN roles. NMs make up about 5% of the midwifery workforce (UNFPA, 2014). Despite smaller numbers, NMs spend more time delivering sexual and reproductive health and maternalnewborn care compared to nurses and generalist physicians, accounting for 14% of full-time equivalents (UNFPA, 2014). Nurse Anesthetist Globally, the current status of NAs is not well described. In the last international surveys published 20 years ago, 107 countries were found to have nurses providing anesthesia care (McAuliffe & Henry, 1996, 1998). Survey results demonstrated the significant magnitude of anesthesia nursing across developed and developing countries. Nurses were involved in 83% of all procedures and were the sole provider for over 51% of procedures, especially in rural communities (McAuliffe & Henry, 1998). The education and scope of practice of NAs varies across countries and does not consistently meet requirements for APN roles in all situations. Country profiles provided by the International Federation of Nurse Anesthetists (2017) show that in the United States, Jamaica, France, and Sweden, the NA is an advanced role requiring graduate education. In other countries such as Cambodia, Congo, Ghana, Indonesia, Switzerland, and Tunisia, NAs require a postbasic nursing diploma or certificate taking 2 to 3 years to complete. In the United Kingdom, NAs complete a 9month postbasic education program and function as anesthesia assistants, while in Taiwan they complete hospital-based training programs specific to each institution. In Brazil, China, Israel, and Spain, a regulatory framework for NAs does not exist and access to education is limited (Aaron & Andrews, 2016; Hu, Fallacaro, Jiang, Wang, & Ruan, 2013; Lemos & Peniche, 2016). Education programs in Nordic countries range from hospital-based training to master's degrees, but they have similar entry requirements (i.e., registered nurse with 1 or 2 years of work experience), and four out of the five countries have a protected title of NA (Jeon, Lahtinen, Meretoja, & Leino-Kilpi, 2015). Nurse Practitioner The NP role was first launched in the United States in 1965, followed by Canada and Jamaica in the mid-1970s, with the aim to improve people's health by increasing access to primary health care for vulnerable populations with high needs and those living in rural, remote, and underserved communities (Jamaica Association of Nurse Practitioners, 2016; Kaasalainen et al., 2010; Saver, 2015). In the 1980s, Canada and the United States introduced acute care NPs, beginning with a focus on neonatal care, to address shortages of physicians and to meet the complex care needs of acute and critically ill patients (Haut & Madden, 2015; Kilpatrick et al., 2010). Countries such as Australia (Carter, Owen-Williams, & Della, 2015), Ireland (Begley et al., 2010), the Netherlands (De Bruijn-Geraets, Van Eijk-Hustings, & Vrijhoef, 2014), New Zealand (Gagan, Boyd, Wysocki, & Williams, 2014), Sweden (Altersved, Zetterlund, Lindblad, & Fagerstrom, 2011), Taiwan (Chiu, Tsay, & Tung, 2015), Thailand (Hanucharurnkul, 2007), and the United Kingdom (East, Knowles, Pettman, & Fisher, 2015) introduced NPs in the 1990s and early 2000s. Exemplar 6.1 provides a profile of the NP role in Australia. The United States has 220,000 NPs, of which 83% are certified in primary care (American Association of Nurse Practitioners, 2016). Countries such as Australia (n = 1214), Canada (n = 4090), Ireland (n = 141), the Netherlands (n = 2749), and New Zealand (n = 142) have smaller numbers of NPs and fewer working in primary care compared to the United States, but trends indicate a growing number of NPs in this sector (Freund et al., 2015; Maier, Barnes, Aiken, & Busse, 2016). The settings where NPs work are also expanding to meet the health needs of aging populations and those with chronic conditions. NPs work in hospitals, outpatient clinics, group practices, public health, emergency departments, community health centers, hospices, and long-term care (American Association of Nurse Practitioners, 2016; Donald, Martin-Misener, et al., 2010; Donald et al., 2013; Kilpatrick et al., 2010; MatenSpeksnijder, Pool, Grypdonck, Meurs, & van Staa, 2015). Exemplar 6.1 Profile on the Nurse Practitioner Role in Australia Margaret Adams NP, PhD Candidate, Glenn Gardner Professor, Queensland University of Technology Nurse practitioner (NP) service in Australia is relatively new, with the first NP authorized in 2000. The NP title is protected by legislation and to gain NP endorsement, a registered nurse must demonstrate successful completion of an accredited Master of Nursing (Nurse Practitioner) degree and 3 years of experience working as an advanced practice nurse. In Australia, NP authorization is generic and there is no centralized register of specialty fields. In 2016, there were just under 1400 NPs across the country working in emergency departments, community and primary health, geriatric care, rehabilitation, and a range of acute care specialties. In 2010 the Australian government invested nearly $60 million to expand the role of NPs in the health system, with legislative changes that enabled eligible NPs to access governmentsubsidized health care for their patients though the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Although access is currently limited to a small range of specified items, this move has had an important influence on the shift of NP service from almost exclusive employment in government-funded acute care facilities to the primary care context in a range of innovative service models. This belated but important expansion of NP service into the primary care sector in Australia is supported by education standards mandating a foundation of primary health care in an accredited master's degree. In countries with established roles (e.g., Australia, Canada, Ireland, Jamaica, the Netherlands, New Zealand, and the United States) NPs are required to have a master's degree, but in other countries the education and regulatory requirements for NPs are evolving and varied (Heale & Rieck-Buckley, 2015). A distinguishing feature of NP roles is an expanded scope of practice with competencies in advanced health assessment, ordering diagnostic tests, communicating a diagnosis, prescribing treatments and medication, and performing procedures (Canadian Council of Registered Nurse Regulators, 2015; De Bruijn-Geraets et al., 2014; Gagan et al., 2014). There is some overlap in role responsibilities between NPs and CNSs, but due to their clinical expertise and expanded scope of practice, NPs tend to spend more time than CNSs providing direct clinical care (Donald, Bryant-Lukosius, et al., 2010; Gardner, Duffield, Doubrovsky, & Adams, 2016; National Council of State Boards of Nursing [NCSBN], 2007). The effectiveness of NPs is well established. Several systematic reviews show that when compared to standard care, NPs have similar or improved outcomes related to patient health, satisfaction with care, quality of care, and health care use (Donald et al., 2015; MartinMisener et al., 2015; Stanik-Hutt et al., 2013). Clinical Nurse Specialist The CNS role was introduced in the United States, Canada, and the United Kingdom in the 1960s and 1970s in response to the rising complexity and specialization of health care and the need for clinical expertise, education, and leadership to improve care delivery and patient outcomes, develop nursing practice, and support nurses at the point of care (Fulton, 2014; Kaasalainen et al., 2010; Leary et al., 2008). In the 1990s and 2000s, CNSs were further introduced in China, Hong Kong, Japan, New Zealand, the Republic of Korea, Taiwan, and Thailand (Kaur, 2014; Roberts, Floyd, & Thompson, 2011; Tian et al., 2014; Wongkpratoom, Srisuphan, Senaratana, Nantachiapan, & Sritanyarat, 2010). The United States has 70,000 CNSs, compared to 55,000 in the United Kingdom and 2000 in Canada (Kilpatrick et al., 2013; National Association of Clinical Nurse Specialists, 2016; Royal College of Nursing, 2012b). CNS education varies across countries, and this, coupled with inconsistent role titling, including the generic term advanced practice nurse, makes it difficult to discern specialized versus advanced CNS roles (Dury et al., 2014; Kilpatrick et al., 2013). CNSs work in a variety of specialty areas that may be defined by a type of illness (e.g., cancer, cardiovascular disease), health needs (e.g., pain control, mental health), type of care (e.g., wound or critical care), setting (e.g., community), or age (e.g., neonatal, gerontology) (BryantLukosius et al., 2010; Roberts et al., 2011; Vidall, Barlow, Crow, Harrison, & Young, 2011). Although CNSs were initially introduced in hospitals, the role has spread to provide specialized care for patients with complex and chronic conditions in outpatient, emergency department, home, community, and long-term care settings (Kilpatrick et al., 2013; Roberts et al., 2011; Tian et al., 2014; Vidall et al., 2011). Depending on the country, and unlike other types of APN roles, CNSs may not have an expanded scope of practice that includes activities such as diagnosis or prescribing. Practice pattern studies illustrate the complexity of CNS work (Kilpatrick et al., 2013; Leary et al., 2008; Roberts et al., 2011). When compared to NPs, CNS are more likely to engage in multiple role activities (clinical, consultation, leadership, quality improvement, evidence-based practice, and research) and have greater involvement in nonclinical activities (Donald, Bryant-Lukosius, et al., 2010; Gardner et al., 2016; NCSBN, 2007). Positive patient health (e.g., survival rates) and health system (e.g., quality of care, service use, costs) outcomes resulting from CNS roles that complement or substitute for other health care providers are consistently reported in systematic reviews (Bryant-Lukosius, Carter, et al., 2015; Kilpatrick et al., 2014; Kilpatrick, Reid, et al., 2015; Newhouse et al., 2011). Nurse Consultant The NC role exists in Australia, the United Kingdom, and Hong Kong. The role was first introduced in Australia in 1986 and was modeled after the CNS role in the United States and the United Kingdom (O'Baugh, Wilkes, Vaughan, & O'Donohue, et al., 2007). Three grade levels differentiate increasing NC responsibilities across five role domains (clinical service and consultancy, clinical leadership, research, education, and clinical service planning); incremental work experience as a registered nurse (5–7 years) and specialty experience (0–5 years); and postbasic registration qualifications (New South Wales Department of Health, 2011). NC education in Australia is variable, ranging from a hospital certificate to a master's degree (Baldwin et al., 2013). In the United Kingdom, the NC role was introduced in the early 2000s and requires master's education and specialty experience. Role domains (direct care, professional leadership and consultancy, education and training, and service development) are similar to Australian NC roles (Gerrish, McDonnell & Kennedy, 2013). The NC sits at level 8 near the top of the nine-level nursing career framework in the United Kingdom (Royal College of Nursing, 2012a). In Hong Kong, the NC role was introduced in 2009 with similar requirements, including master's education and 8 years of experience in one of five clinical specialties (diabetes, renal, wound/stoma, psychiatry, and continence) (Lee et al., 2013). Role domains include clinical practice, academics, research, and leadership. NCs were introduced to retain experienced nurses in clinical practice by broadening the career path (Cashin, Stasa, Gullick, Conway, & Buckley, 2015; Gerrish et al., 2013; Lee et al., 2013) and to improve the quality of care and outcomes for patients (Kennedy et al., 2011). Studies show that NCs manage complex patient and health care situations (Franks, 2014; Jannings, Underwood, Almer, & Luxford, 2010; Lee et al., 2013) and positively impact patient, health professional, organization, and systems outcomes (Cashin et al., 2015; Gerrish et al., 2013; Kennedy et al., 2011; Wong et al., 2017). These areas of impact are similar to those reported for CNSs in the United States (Lewandowski & Adamle, 2009). Similarities between the NC and CNS roles in the United States and Canada have been noted in literature reviews (Duffield, Gardner, Chang, & Catlin-Paull, 2009; Jokiniemi, Pietila, Kylma, & Haatainen, 2012). New Frontiers and Future Role Expansion There has been trendsetting growth in APN role development in Europe over the last decade. Sweden established an acute care NP education program in addition to an earlier focus on primary care (Jangland et al., 2014), and APN roles and education programs are emerging or established in Denmark, Finland, Iceland, and Norway (Hølge-Hazelton, Kjerholt, Berthelsen, & Thomsen, 2016; Oddsdottir & Sveinsdottir, 2011; Pill, Kolbaek, Ottmann, & Rasmussen, 2012; Wisur-Hokkanen, Glasberg, Makela, & Fagerstrom, 2015). The profile by Krista Jokiniemi describes the CNS role in Finland (Exemplar 6.2). In Spain, the advanced nurse specialist has been defined for midwifery, mental health, occupational health, geriatrics, pediatrics, and family/community nursing (Gonzalez Jurado, 2015), along with APN competencies for research and evidence-based practice, clinical and professional leadership, and care management (Sastre-Fullana, De Pedro-Gømez, Bennasar-Veny, Serrano-Gallardo, & Morales-Asencio, 2014). Innovative roles are also emerging to meet the needs of patients with complex comorbid conditions (del Rio Camara et al., 2015). In Switzerland, work has taken place to define (Morin, Ramelet, & Shaha, 2013), regulate (Swiss Association for Nursing Science, 2012), and evaluate APN roles (Bryant-Lukosius et al., 2016). The number of Swiss APN education programs has increased along with graduates working with varied patient populations (Imhof, Naef, Wallhagen, Schwarz, & Mahrer-Imhof, 2012; Kocher & Spichiger, 2014; MüllerStaub et al., 2015; Romain-Glassey et al., 2014; Serena et al., 2015). Exemplar 6.2 Profile on Emerging Advanced Practice Nursing Roles in Finland Krista Jokiniemi Postdoctoral Fellow, University of Eastern Finland and McMaster University Advanced roles for nurses emerged in Finland at the beginning of the 21st century with the introduction of the clinical nurse specialist (CNS) role. Other established advanced practice nursing (APN) roles include the nurse-midwife, nurse anesthetist, and more recently the nurse practitioner. Although there is a long history of specialist nursing practice and education in Finland, the concept of the advanced practice nurse at the national level is just beginning. There are no uniform national education programs, legislative or regulatory mechanisms, or protected titles in place for APN roles. Currently, there are close to 60 CNSs across the country working in inpatient units, clinics, and primary care. They develop specialized expertise through practice experience and master's degree education. CNSs operate in four distinct yet interrelated role spheres related to the patient, nursing, organization, and scholarship. Within each sphere, six domains of advanced clinical practice, practice development, education, research, consultation, and leadership may be enacted depending on organizational needs, set goals, and skills of the individual practitioner. The main practice goal is to improve the quality of care, support staff and interprofessional teams in care provision, and foster the advancement of clinical nursing through scholarship. Strengthening APN roles is high on the health care agenda in Finland. Health care administrators have recognized the value of these roles for improving nursing practice, promoting evidence-based practices, strengthening the image of nursing, and increasing nursing recruitment and retention. To support the effective implementation of APN roles, it will be imperative to develop and validate competency descriptions, elaborate on role domain concepts, develop education curricula, and demonstrate the effectiveness of these innovative nursing roles. APN roles are not formally recognized in Africa. However, in subSaharan countries such as Kenya (East, Arudo, Loefler, & Evans, 2014) and in South Africa (Duma et al., 2012) the roles are needed to improve population health, increase access to care, improve care quality, and develop the nursing workforce. Due to provider shortages, especially in primary care, nurses and NMs may acquire an expanded scope of practice similar to APN roles in other countries but without the benefit of graduate education (East et al., 2015; Ugochukwu, Uys, Karani, Okoronkwo, & Diop, 2013). In South Africa, master's-prepared advanced practice nurses are emerging in primary health care, midwifery, psychiatry, and pediatrics (Duma et al., 2012; South African Nursing Council, 2012; Temane, Poggenpoel, & Myburgh, 2014). In Middle Eastern countries, APN roles have been introduced to expand, heighten the profile of, and modernize nursing and midwifery workforces. To overcome a reliance on foreign-trained nurses, countries such as Jordan (Zahran et al., 2012), Qatar (Hamad Medical Corporation, 2015), and Saudia Arabia (Brownie, Hunter, Aqtash, & Day, 2015) have launched graduate programs in critical care, maternal/newborn care, renal care, oncology, diabetes, and community health. Education programs for NMs, palliative care CNSs, and geriatric NPs have also been established in Israel (Aaron & Andrews, 2016; Livneh, 2011; Yafa, Dorit, & Shoshana, 2016). CNSs and family NPs are being introduced in Oman (Al-Maqbali, 2014; Almukhaini, Donesky, & Scruth, 2016). English language publications do not fully describe APN role development in Asia, but several new education initiatives exist. They include APN graduate programs in Singapore and China (Ayre & Bee, 2014; Wong et al., 2010), an NP graduate program in Japan (Fukuda et al., 2014), and NP programs offering a Master's of Science degree in critical care and a postgraduate diploma in primary health care in India (Olabode, 2016). Needs related to improving care for aging populations, provider shortages, and chronic disease management were the main drivers for these programs. The profile by Frances Kam Yuet Wong describes APN role development in China (Exemplar 6.3). Exemplar 6.3 Profile on Advanced Practice Nursing Role Development in China Frances Kam Yuet Wong Professor, Hong Kong Polytechnic University China is a vast country consisting of 23 provinces, 5 autonomous regions, 4 municipalities, and 2 Special Administrative Regions (Hong Kong and Macau). Factors facilitating the introduction of advanced practice nursing (APN) roles include the national strategy to develop “Healthy China”; the national strategy to develop nursing, which highlights the importance of specialization in nursing practice; and elevation of the status of nursing from a second-class to first-class subject in 2011. With this change, nursing is more autonomous and university departments of nursing can admit postgraduate students. Many schools have introduced clinical master's degree programs that strengthen the preparation of advanced practice nurses. A challenge to introducing APN roles is the shortage of nurses. As of 2015, there were 3.2 million nurses in Mainland China, with a nurse-patient ratio of 2.36. This ratio is very low compared to other developed countries. Although there is a plan to increase the number of nurses, the sheer inadequacy in number will hamper the development of nursing at an advanced level. Another challenge is that structures to support APN roles (e.g., education, competencies) are not well established in the remote areas and less developed cities. Opportunities to develop APN roles are expanding with growing numbers of universityprepared nurses and increased access to graduate education. There are 58 master's and 10 doctoral nursing programs. There are also specific programs sending nurses overseas for specialty training. The Guangdong Province illustrates progress in APN role development in China. From 2004 to 2005, the Hong Kong Polytechnic University provided a consultant course in collaboration with Nanfong Medical University to prepare advanced practice nurses in diabetes care, geriatrics care, intensive care, and infection control. From 2006 to 2011, 614 nurses were sent to Hong Kong for APN education in one of 13 different specialties (intensive care, orthopedics, operating room, geriatrics, midwifery, neonatal/pediatrics, renal, emergency room, cardiac, surgical, oncology, community, and psychiatric nursing). Guangdong now has a critical mass of advanced practice nurses to provide services and impact patient care. The Ministry of Health has also put policies and resources in place to support APN development, including accredited education programs, examination requirements, and employment conditions. The next frontier for introducing APN roles is Latin America, where few such roles exist (Bryant-Lukosius et al., 2017). Countries primed for APN roles are Brazil, Chile, Mexico, and Columbia. With support from the regional nurse advisor and from WHO Collaborating Centres in Primary Health Care in the United States and Canada, meetings have occurred to plan the introduction of APN roles (Pan American Health Organization [PAHO] & School of Nursing, McMaster University, 2015; PAHO & University of Michigan, 2016). Primary health care reform, access to health care, and universal health care coverage are the policy drivers for APN roles in the region. The profile by Consuelo Cerón Mackay describes APN role development in Chile (Exemplar 6.4). Exemplar 6.4 Profile on Advanced Practice Nursing Roles in Chile Maria Consuelo Cerón Mackay Director of the School of Nursing, Los Andes University, Chile Interest in advanced practice nursing (APN) roles in Chile began in the late 1990s, when the School of Nursing of Universidad de los Andes recognized the need to develop clinical master's programs. At that time most graduate programs focused on developing nurses for an academic career. In 2001, a faculty member was sent to study in an APN program at New York University. On her return she was challenged to educate other faculty members about APN roles. The curriculum from New York University was used as a reference point, particularly for the clinical nurse specialist (CNS) role, because it was most suitable for Chilean health care needs focused on hospital care. In 2009, two faculty members visited the University of Pennsylvania, the University of California at San Francisco, and the Johns Hopkins School of Nursing to learn about APN education programs and to establish a support network. A memorandum of understanding was signed with the Institute for Johns Hopkins Nursing that allowed our students to spend 3 weeks at the Johns Hopkins Hospital to observe CNSs in action and develop their understanding of the role. Currently, the APN stream is a 2-year program, with the first year focused on theoretical courses and the second on clinical practice. Physicians are acting as tutors for the students until enough CNSs have graduated to become mentors. In addition, a CNS from Johns Hopkins came to Chile for a week to provide intensive education for the students at a local hospital. The program is now 3 years old and has nine graduates. Although recruitment to the program is low, the CNS role is being successfully implemented in practice settings. Moreover, faculty members are sharing their APN education experiences as conference speakers nationally and in other Latin American countries. The invitation to participate at the 2015 Universal Access to Health and Universal Health Coverage APN Summit, organized by the Pan American Health Organization (PAHO) and the School of Nursing at McMaster University, encouraged me to begin the process to implement the nurse practitioner role. This meeting was crucial for guiding and speeding up the planning process. Main accomplishments include establishing a network among 11 nursing schools throughout Chile and developing partnerships with the Chilean Association of Schools of Nursing, the PAHO-Chile, the Ministry of Health, and the Chilean Association of Nurses, to work together to implement the nurse practitioner role in primary health care. In summary, APN role development has occurred mainly in highincome countries. Role expansion is now taking place in upper-middle (e.g., Brazil, China) and lower-middle (e.g., India, Kenya) income countries and may spread to lower-income countries such as Nepal and in Africa. APN roles are needed for strengthening the nursing and midwifery workforce, chronic disease prevention and management, and aging populations. Continued demand for APN roles in primary care is expected due to shortages of physicians (WHO, 2015b). Facilitating the Introduction and Integration of Advanced Practice Nursing Roles Contextual factors (e.g., sociopolitical, economic, geographic) influence the use of APN roles within health care systems, and barriers are often the absent mirror versions of facilitators (DiCenso et al., 2010). Table 6.1 highlights key facilitating factors, including pan- approaches and collaboration, funding and payment arrangements, systematic approaches to role planning, and the use and generation of evidence. Levels of engagement (international, national, and organizational) for successful APN role introduction and integration are examined for each factor. TABLE 6.1 Pan-Approaches and Collaboration Pan-approaches are activities that span across jurisdictions. At the international level this may include activities involving more than one country, and at the national level activities that cut across regions within a country. National and international collaboration related to human resource policies and priorities, legislation and regulation, and competency development and education are strategic for jump starting the introduction and development of APN roles. Human Resource Policies and Priorities At the international level, policy priorities of the United Nations and the WHO have played a critical role in raising the profile and triggering actions for APN role development. For example, United Nations (2012) and WHO (2010) priorities to improve global health influenced the PAHO 52nd Directing Council's (2013) resolution on Human Resources for Health calling for the introduction of APN roles for primary health care in Latin American and the Caribbean (Cassiani & Zug, 2014). This resolution laid the foundation for APN role development and partnerships between the PAHO, regional and international schools of nursing, and WHO Collaborating Centres. A powerful example offering a template for international nursing and APN association leadership and health policy involvement in human resource planning is the collaboration between the ICM, the United Nations, and the WHO to improve the global midwifery workforce (Day-Stirk et al., 2014; UNFPA, 2011, 2014; WHO, 2015a). Through collaboration, agreement on midwifery workforce indicators and targets was established and implemented at national levels, resulting in a detailed data set used to evaluate and compare the impact of workforce policies and initiatives across countries. Early results showed improvement in educating and expanding the number of midwifery providers and in maternal-child health outcomes (UNFPA, 2014). The midwifery example is notable because of its success in workforce development in low- and middle-income countries where health needs are the greatest and where few APN roles exist. The ICM (2015) emphasized the essential role of national midwifery associations in workforce policy and decision making. Similarly, an ICN brief provided guidance on APN role development for national nursing associations (Bryant-Lukosius & Martin-Misener, 2016). A stronger role for nurses, including APN representatives, in international organizations such as the WHO is critical to inform human resource policy priorities and implementation strategies (Wong et al., 2015). At the national level, health care contexts related to needs, policies, organization of services, the workforce, economics, and the societal role of women influence APN roles (Heale & Rieck-Buckley, 2015; Liu, Rodcumdee, Jiang, & Sha, 2015). National practice pattern studies can facilitate role integration by providing information to define APN roles, identify implementation barriers, and assess deployment in relation to policies for improving health (DiCenso et al., 2010; Gardner et al., 2016). The introduction of APN roles may be advantaged in countries with centralized health care governance and national health policies aligned with the roles. One example is Ghana, where national health human resource policies since 1995 have led to a steady increase in midwives (Matthews & Campbell, 2015). Qatar's National Cancer Strategy (2011–2016), with the goal for all cancer patients to be cared for by an oncology CNS (Qatar Supreme Council of Health, 2011), quickly led to the introduction of the role (Oxford Business Group, 2014). A systematic approach to introducing NM and NP roles occurred in Ireland, where the national health ministry worked closely with the national nursing council to deploy roles focused on priorities for health care reform (Begley et al., 2010). By 2009 and within 8 years, Ireland introduced over 120 APN roles, accounting for 0.2% of the nursing workforce (Delamaire & Lafortune, 2010). This is quite an accomplishment when compared to Canada, with just over 1600 NPs in 2008 making up 0.6% of the nursing workforce after 40 years of development. In Canada, responsibility for health care lies with 13 provinces and territories, resulting in disparate NP role deployment (DiCenso et al., 2010). Regulation The regulation of nursing is usually tied to health laws protecting public safety and promotes high-quality care by defining the scope and standards of practice, licensure, credentials, and educational requirements of the profession (ICN, 2013). Internationally, the regulatory requirements for APN roles are variable or absent in many countries (Aaron & Andrews, 2016; Carney, 2015; Heale & RieckBuckley, 2015; Maier, 2015). Legislative and regulatory policies embracing optimal scope of practice and full role autonomy without restrictions (e.g., physician supervision for practice or prescriptions) facilitate NP recruitment and retention and increase access to care, especially for rural and vulnerable populations (Barnes et al., 2016; Kuo, Loresto, Rounds, & Goodwin, 2013; Xue, Ye, Brewer, & Spetz, 2016). Regulatory mechanisms offering title protection and standardized education and competencies have been found to improve NP role clarity and implementation (Duffield et al., 2009; Lowe, Plummer, O'Brien, & Boyd, 2011). Conversely, the lack of regulation for CNS and other types of APN roles contributes to poor role clarity, variability in how roles are operationalized, and inability to monitor their workforce contributions, and may negatively impact role integration and sustainability (Duffield et al., 2009; East et al., 2015; Kilpatrick et al., 2013). Reports of pan-approaches at the international level to improve APN regulation are few and would be an asset for guiding role introduction in low-income countries and those with new or emerging roles. The importance of international collaboration is illustrated by the Global Midwifery Twinning project involving the Royal College of Midwives in the United Kingdom and midwifery associations in Nepal, Cambodia, and Uganda (Ireland, van Teijlingen, & Kemp, 2015). The project was successful in building the capacity of midwives to lead and advocate for stronger midwifery associations, education, and regulation in these countries. At national levels, pan-approaches to legislation and regulation in support of APN roles have been successful in Canada, the United States, New Zealand, and Wales for obtaining greater consistency in these policies, improving role understanding and implementation, and creating ways to monitor deployment across jurisdictions (BryantLukosius et al., 2014; Goudreau, 2014; Kooienga & Carryer, 2015; NCSBN, 2008; Ryley & Middelton, 2015). In many countries, establishing a nursing regulatory framework will be an essential first step in establishing requirements for advanced practice. Ben Natan, Dmitriev, Shubovich, and Sharon (2013) found that the Israeli public was in favor of expanding nurses' scope of practice and authority. Engaging the public in the discourse may be an effective strategy to strengthen legislative and regulatory policies supportive of APN roles. Competency Development and Education Competencies are the knowledge, skills, judgment, and attributes required by advanced practice nurses to provide safe, ethical practice (Canadian Nurses Association, 2010). They are informed by a collective understanding of the APN role and provide the basis for entry-to-practice requirements and APN education curricula. Varied national interpretations of what an advanced practice nurse is have led to a perceived lack of role clarity internationally (Dowling et al., 2013). The ICN's (2008) competencies for the advanced practice nurse, along with recommendations for graduate education, provide nursing associations with a framework to develop competencies for their country and to lobby for these requirements (DiCenso et al., 2010). Studies conducted to examine APN roles across countries suggest that international convergence on defining and understanding APN roles may be occurring. Sastre-Fullana et al. (2014) conducted a review of APN competency frameworks and found agreement on 17 competencies across six types of APN roles in 26 countries. Research, clinical and professional leadership, mentoring and coaching, and expert clinical judgment were common role domains in 16 of 29 countries. Jokiniemi et al. (2012) found similar domains for CNS and NC roles in the United States, Australia, and Finland. In addition, the Advanced Practice Role Delineation tool discerns nurses practicing at an advanced level and differences in activities among varied APN roles (Gardner et al., 2016). There has also been a burst of activity in several countries to establish or refine competencies in order to clarify APN roles and strengthen role implementation (Canadian Nurses Association, 2015; Chang, Shyu, Tsay, & Tang, 2012; Lin, Lee, Ueng, & Tang, 2015; Maijala, Tossavainen, & Turunen, 2015; Nieminen, Mannevaara, & Fagerstrom, 2011). At the international level, pan-initiatives may facilitate the consistency and quality of APN education across countries. For example, in addition to standards for practice and education, the International Federation of Nurse Anesthetists developed an approval process for schools, now completed by 14 education programs in nine countries (Horton, Anang, Riesen, Yang, & Bjorkelund, 2014). The Bologna process aims to standardize all professional education requirements across Europe. This process has accelerated the professionalization of nursing and creation of baccalaureate and master's education programs necessary to develop APN roles (Collins & Hewer, 2014). At national levels, health policies, population health needs, and social factors influence the level and types of APN education (Liu et al., 2015). In many countries, APN role development is limited by a lack of education programs and master's-prepared faculty with APN experience (Heale & Rieck-Buckley, 2015). Partnerships between countries with emerging APN roles and schools of nursing in countries with established roles have occurred to address these education gaps. One such case is in Qatar, where the government partnered with the University of Calgary in Canada to develop undergraduate and graduate nursing education programs (Oxford Business Group, 2014). The leveling of APN education has become somewhat contentious with the requirement of the doctorate of nursing practice for APRNs in the United States (Ketefian & Redman, 2015). This is not an attainable goal in many countries where basic nursing education is being developed or where resources for graduate education are limited. At national levels it is important to keep in mind that a good fit between APN curricula and practice needs is key for optimal role implementation (Martin-Misener et al., 2010). There is limited research on APN education, but a few studies suggest that master's-prepared nurses implement their roles in a manner more consistent with APN standards of practice, compared to non–master'sprepared nurses (Kilpatrick et al., 2013; Pauley et al., 2004). At organizational levels, academic-clinical practice partnerships to provide mentorship and continuing education for advanced practice nurses can help to build their confidence, strengthen skills in underdeveloped areas such as research, and maintain competency (Bryant-Lukosius, 2015; Harbman et al., 2016). Funding and Reimbursement Arrangements Funding at national/regional and organizational levels is essential to introduce and expand the supply of advanced practice nurses to meet demands for health care. In the United States, new funding from the 2010 Patient Protection and Affordable Care Act has increased the number of APRNs providing primary care (Lathrop & Hodnicki, 2014). In Canada, provincial funding for Ontario NPs in primary, palliative, and long-term care enabled role expansion in these high- need areas (Bryant-Lukosius et al., 2014; Heale & Pilon, 2012; Ontario Ministry of Health and Long-Term Care, 2015). Similar expansion has not occurred for CNSs, acute care NPs, or NPs in anesthesia care in the absence of provincial funding. At an organizational level, advanced practice nurses are most often an operational cost as salaried employees. External funds or reallocated existing funds are required by organizations to introduce, maintain, or expand APN roles and may be difficult to obtain in challenging economic conditions (Gagan et al., 2014). Results of systematic reviews examining APN outcomes demonstrate that advanced practice nurses may reduce health care inefficiencies in 5 out of 10 areas identified by the WHO (Bryant-Lukosius et al., 2017). Using similar data to create a sound business case may help health care organizations identify efficiencies and cost savings that can be gained by the innovative use of APN roles and applied to offset salary costs. Fee-for-service reimbursement models for advanced practice nurses exist in the United States and in Australia for primary care NPs (Carter et al. 2015). In the United States, pediatric and family NPs, NMs, and to a lesser extent NAs and CNSs can bill Medicaid and third-party payers such as insurance companies (American Nurses Association, 2016). Such models provide economic flexibility to increase access to care and introduce new services involving APN roles, especially for high-risk, low-income, and underserved populations (Barnes et al., 2016). The recruitment of advanced practice nurses is enhanced when policies ensure that they are reimbursed at the same funding level as physicians (Barnes et al., 2016). Reimbursement policies may partially explain differences among countries in the number of NPs making up the nursing workforce, as a crude indicator of health systems integration. Compared to other countries with established roles, the United States has a larger proportion of NPs in the nursing workforce (5.6% vs 1.5% or less) (Maier et al., 2016). Physician support is key for optimal NP role implementation and can be fostered by mitigating NP impact on physician income. Reimbursement models not reliant on physician fee-for-service reimbursement and that support collaboration with NPs are advantageous in that regard (DiCenso et al., 2010). Systematic Approaches to Role Planning APNs have been described as providing complex care interventions characterized by using multiple interacting competencies and having responsibilities for addressing difficult health care problems and improving outcomes for a variety of groups (e.g., patients, families, providers, teams, organizations, health systems) (Bryant-Lukosius, Israr, Charbonneau-Smith, & DiCenso, 2013). Several factors (e.g., competencies, education, regulation, legislation, funding) are required for successful role implementation. Numerous studies indicate that these factors are often not in place, resulting in serious challenges to APN role implementation and pointing to the need for more systematic approaches to role planning (Andregard & Jangland, 2014; Higgins et al., 2014; Jarosova et al., 2016; Lecocq, Mengal, & Pirson, 2015; Sangster-Gormley, Martin-Misener, Downe-Wamboldt, & DiCenso, 2011). One such approach is the PEPPA (Participatory, Evidence-Based, Patient-Focused Process for Advanced Practice Nursing) framework, offering a nine-step participatory, evidencebased, patient-focused, process for APN role development, implementation, and evaluation. The framework can be used by decision makers, researchers, educators, and nurses at national, regional, organizational, practice setting, or team levels to address barriers to effective APN roles related to role clarity, use of APN expertise, scope of practice, supportive practice environments, and ongoing development and evaluation (Bryant-Lukosius & DiCenso, 2004) (see Chapter 4). PEPPA incorporates principles for effective health human resource planning and has been used successfully to introduce APN and other provider roles in at least 16 countries (Boyko, Carter, & Bryant-Lukosius, 2016). Involving stakeholders (e.g., patient advocates, policymakers, managers, providers) early on in the process is essential for successful APN role implementation (Schober, Gerrish, & McDonnell, 2016). A major strength of PEPPA is the use of stakeholder engagement strategies to determine the need for and define the role, obtain role acceptance and support, and anticipate and resolve implementation barriers (Bryant-Lukosius et al., 2013). At organizational levels, health care administrators are pivotal for guiding the role planning and introduction process, and providing leadership and resources to support role implementation and evaluation (Carter et al., 2010; Elliott, Begley, Sheaf, & Higgins, 2016; Heale, Dickieson, Carter, & Wenghofer, 2014). Use and Generation of Evidence Linked with poor planning and the lack of systematic approaches to introducing APN roles is the fact that existing evidence is often not used to inform this process and that influential stakeholders (e.g., government policymakers, health care administrators, health care team members, and the public) at all health system levels (international, national, organizational) do not have a good understanding of the roles (Andregard & Jangland, 2014; DiCenso et al., 2010; Schober et al., 2016; Wisur-Hokkanen et al., 2015). To address these issues, PEPPA promotes the use of existing data for making decisions at each step of APN role development, and it is through this process that stakeholders become more knowledgeable and accepting of the roles. Other strategies are also required to engage and inform stakeholders. Conducting a stakeholder analysis is beneficial for identifying the levels of support, influence, and priorities of key decision makers (Bryant-Lukosius, 2009; Schober et al., 2016). APN champions can then be identified and leveraged to deliver evidence-based messages that are tailored to address the varied information needs of different stakeholders. Using multiple strategies to deliver tailored information in person and electronically, and in concise formats such as briefing notes, facilitates receipt of key messages by busy decision makers (Carter et al., 2014; Kilpatrick, Carter, et al., 2015). The INP/APNN is a special interest group of the ICN that supports APN role development by providing information and creating forums, such as a biannual conference, for information sharing and networking (ICN, 2016a). INP/APNN committees focus on issues related to practice, education, policy, and research and facilitate international surveys to examine APN role practice patterns (Heale & Rieck-Buckley, 2015; Pulcini, Jelic, Gul, & Loke, 2010). Numerous systematic reviews of randomized controlled trials conducted over the past 35 years demonstrate the effectiveness of APN roles, especially in high-income countries (Bryant-Lukosius, Carter, et al., 2015; Bryant-Lukosius, Cosby, et al., 2015; Donald et al., 2013, 2015; Johantgen et al., 2012; Kilpatrick et al., 2014; Kilpatrick, Reid, et al., 2015; Martin-Misener et al., 2015; Morilla-Herrera et al., 2016; Newhouse et al., 2011; Stanik-Hutt et al., 2013; Swan, Ferguson, Chang, Larson, & Smaldone, 2015; Tsiachristas et al., 2015). Further research is needed on the cost-effectiveness of APN roles (Marshall et al., 2015), and guidelines to facilitate economic evaluations of these roles are being developed (Lopatina et al., 2017). Given the consistency of evidence about their effectiveness, future research should focus on understanding the conditions, patient populations, and settings where APN roles are most effective for improving patient and health system outcomes (Bryant-Lukosius et al., 2013). The successful introduction of APN roles can also be informed by research to evaluate the effectiveness of implementation processes. Recently, the PEPPA framework was enhanced to support evaluations and the generation of meaningful data for effective decision making about APN roles at national, organizational, setting, and team levels (Bryant-Lukosius et al., 2016). Called PEPPA-Plus, the framework provides guidance and tools to address the information needs of different decision makers across three stages of APN role development (introduction, implementation, and long-term sustainability). At international and national levels, better health human resource data and agreement on indicators and targets for health systems integration for all types of APN roles will be essential to ensure their adequate supply and optimal deployment to areas of greatest need. Next Steps in the Global Evolution of Advanced Practice Nursing Roles Improving human resources for health will continue to be a global priority as outlined by the WHO's (2016) strategic plan, Health Workforce 2030. Strategic plan objectives and milestones related to investments in the health workforce, needs-based workforce planning, improved access and quality of education, and optimizing provider scopes of practice will benefit the global development of APN roles. Thus the next 15 years will provide exciting opportunities to expand the contribution of APN roles for improving global health. At the international level, nursing organizations and leaders can employ a variety of strategies to support the global development of APN roles, especially in countries where the roles do not exist or are just emerging. These strategies are summarized in Box 6.1. Strategies nursing organizations and leaders can use to support APN role development at country levels are summarized in Box 6.2. Box 6.1 International-Level Strategies to Support the Global Development of Advanced Practice Nursing Roles • Leverage and share expertise and resources for APN education, practice, and policy across countries • Improve role clarity by working toward greater consensus on role definitions and terminology, including delineation of specialized roles at an advanced level • Support policies that build capacity and prevent the outmigration of nursing leaders, educators, researchers, and advanced practice nurses from countries where APN roles are just getting started Adapted from Bryant-Lukosius and Martin-Misener (2016), Dury et al. (2014), Kooienga and Carryer (2015), Nardi and Diallo (2014), and the National Nursing Centres Consortium (2014). Box 6.2 Country-Level Strategies to Support Advanced Practice Nursing Role Development • Focus efforts on placing nurses at high-level policy decisionmaking tables to advocate for the APN role • Advocate for systematic and evidence-based approaches to role development, implementation and evaluation • Connect with key stakeholders around shared policy concerns to create conditions for healthcare organization and system transformational change • Build consensus among stakeholders on health systems solutions that utilize APN roles • Establish a knowledge translation plan to promote stakeholder awareness and understanding of APN roles and their benefits and to reduce barriers to role implementation • Create communities of practice to develop advanced practice nurses Adapted from Bryant-Lukosius and Martin-Misener (2016) and the National Nursing Centres Consortium (2014). Conclusion To date, high-income countries have benefited the most from the introduction and expansion of APN roles. Despite substantial evidence of APN role effectiveness for improving health outcomes, increasing access and quality of care, and reducing the unnecessary use of costly acute care services, the overall integration of APN roles within health care systems is limited in most countries. Over the next decade, policy priorities to improve global health by strengthening the development and use of nursing expertise will create new prospects to expand the introduction of APN roles. Successful health systems integration of the next generation of APN roles will require panapproaches, including international collaboration, greater attention to the use of systematic approaches, and collection and use of good data to identify implementation barriers and monitor role deployment and impact. 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In this chapter the term advanced practice nurse (APN) is used to reflect the international variability in APN role titling and regulation. PA R T I I Competencies of Advanced Practice Nursing OUTLINE Chapter 7 Direct Clinical Practice Chapter 8 Guidance and Coaching Chapter 9 Consultation Chapter 10 Evidence-Based Practice Chapter 11 Leadership Chapter 12 Collaboration Chapter 13 Ethical Decision Making CHAPTER 7 Direct Clinical Practice Mary Fran Tracy “You can only lose something that you have, you cannot lose something that you are.” —Eckhart Tolle CHAPTER CONTENTS Direct Care Versus Indirect Care Activities, 144 Six Characteristics of Direct Clinical Care Provided by Advanced Practice Nurses, 147 Use of a Holistic Perspective, 149 Holism Described, 149 Holism and Health Assessment, 149 Nursing Model or Medical Model, 150 Formation of Therapeutic Partnerships With Patients, 150 Shared Decision Making, 151 Cultural Influences on Partnerships, 154 Communication With Patients, 155 Therapeutic Partnerships With Noncommunicative Patients, 155 Expert Clinical Performance, 156 Clinical Thinking, 157 Ethical Reasoning, 160 Skillful Performance, 161 Use of Reflective Practice, 163 Use of Evidence as a Guide to Practice, 164 Evidence-Based Practice, 165 Theory-Based Practice, 166 Diverse Approaches to Health and Illness Management, 167 Interpersonal Interventions, 167 Therapeutic Interventions, 167 Individualized Interventions, 169 Complementary Therapies, 171 Clinical Prevention, 171 Management of Complex Situations, 173 Helping Patients Manage Chronic Illnesses, 175 Direct Care and Information Management, 176 Conclusion, 177 Key Summary Points, 178 Direct care is the central competency of advanced practice nursing. This competency informs and shapes the execution of the other six competencies. Direct care is essential for a number of reasons. To consult, collaborate, and lead clinical staff and programs effectively, an advanced practice registered nurse (APRN) must have clinical credibility. With the deep clinical and systems understanding that APRNs possess, they facilitate the care processes that ensure achievement of outcomes for individuals and groups of patients. Advanced practice occurs within a health care system that is constantly changing—changing delivery models, reimbursement structures, regulatory requirements, population-based management, and even proposed changes in the basic educational requirements for advanced practice nurses through the Doctor of Nursing Practice (DNP) degree. The challenge that many APRNs face is how to maintain the characteristics of care that have helped patients achieve positive health outcomes and afforded APRN care a unique niche in the health care marketplace. Characteristics such as the use of a holistic perspective and formation of therapeutic partnerships with patients to co-implement individualized health care are challenged by cost containment strategies that emphasize standardization of care to achieve population-based outcome targets. Conversely, characteristics of APRN care such as health promotion, fostering self-care, and patient education are valued by practices offering care to patients because they result in an appropriate use of health care resources and sustain quality. This chapter describes the direct clinical practice of APRNs and helps readers understand how it differs from the practice of experts by experience, describes strategies for balancing direct care with other competencies, and describes strategies for retaining a direct care focus. The six characteristics of APRN direct care practice are identified. Direct Care Versus Indirect Care Activities Direct care is the central APRN competency (see Chapter 3). The APRN is using advanced clinical judgment, systems thinking, and accountability in providing evidence-based care at a more advanced level than the care provided by the expert registered nurse (RN). The APRN is prepared to assist individuals through complex health care situations by the use of education, counseling, and coordination of care (American Association of Colleges of Nursing [AACN], 2006). Although an expert RN may, at times, demonstrate components of care that are at an advanced level, it is care that is gained through experience and is exemplary (not expected) at that level. Essentials I and II of DNP education for APRNs delineate that APRN-level care is demonstrated through advanced, refined assessment skills and implementation and evaluation of practice interventions based on integrated knowledge from a number of sciences, such as biophysical, psychosocial, behavioral, cultural, economic, and nursing science (AACN, 2006). Graduate-level APRN education provides a foundation for the evolution of practice over time as necessitated by health care and patients. This advanced level of practice is an expected competency of all APRNs, not an exemplary skill that is intermittently or inconsistently displayed by staff or expert nurses. For the purposes of this chapter, the terms direct care and direct clinical practice refer to the activities and functions that APRNs perform within the patient-nurse interface. Depending on the focus of an APRN's practice, the patient may, and often does, include family members and significant others. The activities that occur in this interface or as direct follow-up are unique because they are interpersonally and physically co-enacted with a particular patient for the purpose of promoting that patient's health or well-being. Many important processes transpire at this point of care (Box 7.1). Box 7.1 Examples of Processes That Occur at the Point of Care • The patient-provider therapeutic partnership is established. • Health problems become mutually understood through information gathering and effective communication. • Health, recovery, or palliative goals are expressed by the patient. • Management and treatment options are explored. • Physical acts of diagnosis, monitoring, treatment, and pharmacologic and nonpharmacologic therapy are performed. • Education, support, guidance and coaching, and comfort are provided. • Decisions regarding future actions to be taken by each party are made. • Future contact is planned. Advanced practice nursing activities occurring before and adjacent to the patient-nurse interface have a great influence on the direct care that occurs; however, they are not performed with an individual patient or their main purpose is tangential to the direct care of the patient. Activities such as collaboration, consultation, and mentoring of staff may all be occurring in relation to the direct care interface. It is often difficult to separate out these indirect care interventions, which are equally necessary for adequate fulfillment of the APRN role and care of the patient (Box 7.2). For example, when an APRN consults with another provider regarding the nature of a patient's condition or the care that should be recommended to a patient, the APRN is engaging in advanced clinical practice, but it is not direct care. Even though the APRN is accountable for the consultation, the primary purpose of that contact is to acquire information and understanding to use in formulating recommendations for the patient's direct care provider (see Chapter 9). Thus, according to the definition of direct care used in this chapter, the APRN is engaged in clinical practice but he or she is not providing direct care to the patient. The direct care role of the clinical nurse specialist (CNS) may not be as apparent to observers as it is for a nurse practitioner (NP), certified registered nurse anesthetist (CRNA), and certified nurse-midwife (CNM) because the CNS frequently shifts from direct to indirect activities depending on the situation and the providers involved. For the CNS, these shifts may occur during one patient encounter, and certainly across a day. Most APRNs will have a role in ensuring that others are providing quality and safe care through indirect practice (Exemplar 7.1). Box 7.2 Examples of Advanced Practice Nurse Indirect Care Activities • Consultation with other health care providers (e.g., physicians, nurses, pharmacists) • Discharge planning • Care coordination • Communication with insurance organizations • Education of bedside nurses • Unit rounds • Researching evidence-based care guidelines • Leading quality-of-care initiatives • Support staff supervision • Billing and coding • Compliance monitoring • Budget development and implementation Exemplar 7.1 Direct and Indirect Care Provided by Advanced Practice Nursesa Direct Care The care of patients with pulmonary hypertension is commonly managed in the outpatient environment. When those receiving continuous prostacyclin infusion therapy via tunneled central line come back to the hospital for treatment or testing, M.P., the cardiovascular clinical nurse specialist, completes a physical assessment of the patient's current condition and response to therapy. Standard medical assessment of patient response to changes in prostacyclin therapy includes magnetic resonance imaging (MRI). Because the home infusion pump that delivers the medication cannot be taken into the MRI environment, and because disruption of the infusion can lead to significant complications (including rebound pulmonary hypertension), M.P. works directly with the patient to identify the safest method to continue therapy during the scan. After collecting information about the patient's medication, dose, and pump type, M.P. interviews the patient to assess: how the patient is feeling in response to current therapy; the longest period of time the patient has gone without the infusion medication; and how he or she tolerated the pause in therapy. The plan for continuing therapy during the MRI is established based on this data collection. If the patient's infusion pump can function when adequate lengths of tubing are added to the basic infusion set to reach into the MRI area, leaving the pump outside the magnetic field, then M.P. works with the patient to either pre-prime the additional tubing at home or in the preparation area of MRI. Review of the plan for the study and answering the patient's questions and concerns with expertise eases the patient's concerns about undergoing the test. If the patient's pump will not function appropriately with additional lengths of tubing, M.P. collaborates with a pharmacist experienced in the use of intravenous prostacyclins. M.P. and the pharmacist establish an appropriate concentration of medication to be used during the test, calculate the rate needed to achieve the same dose as the patient has been receiving at home, and order both the medications to use during the test and a syringe of medication in the same concentration as the home concentration to use in repriming the patient's central line. After reviewing with the patient the steps to be taken, M.P. helps the patient to convert to the hospital-based infusion prior to the MRI, then assists with conversion back to the home pump at the end of the study. Using advanced assessment skills, M.P. assesses the patient's tolerance of these transitions as well as any side effects he or she may experience during the transitions. Advanced clinical assessment and planning skills are critical in managing patients in this population. Complex care planning, early identification of complications if they occur, and the ability to safely resolve those issues exemplify the importance of the advanced practice registered nurse's role in care of this very challenging patient population. Indirect Care The medical intensive care unit acute care nurse practitioner (ACNP) was approached by an experienced staff nurse who was struggling to develop an interpersonal relationship with the family of a complex, critically ill patient. The family was very anxious and was having difficulty synthesizing the information that the staff nurse was trying to provide to them. Rather than intervene directly with the family, the ACNP recognized that this would be a good opportunity for the staff nurse to develop and expand her skills at interpersonal relationship building. The ACNP explored with the nurse the interventions that she had already attempted and reviewed with her the literature regarding family stressors in critical care, family needs, and the goal of assessing and addressing what the family perceives as their educational and care needs. Armed with this information, the nurse felt comfortable in working with the family to assess their priority educational and psychosocial needs to obtain the resources and information they needed. The ACNP could have intervened by establishing a direct relationship with the family, which would have been providing direct care. In this case, however, she determined that it was more important to assist the staff nurse in the development of the relationship as a growth opportunity and to help the nurse form an ongoing partnership with the family, with whom she would be interacting on a continuing basis. a The author gratefully acknowledges Michael Petty, PhD, RN, APRN, CNS, for use of his direct care exemplar. APRN roles tend to diverge when comparing the amount of time spent in each of the direct care activities (Becker, Kaplow, Muenzen, & Hartigan, 2006; Verger, Marcoux, Madden, Bojko, & Barnsteiner, 2005). A research study by Oddsdottir and Sveinsdottir (2011) has demonstrated that CNSs spend most of their time in education and expert practice in the institutional domain; the authors recommended that the focus for CNSs needs to be on direct practice in the client/family domain. Critical care CNSs reported spending 36% of their time with nursing personnel, 21% with patient population work, and 17% on organizational and system work. Only 26% of their time was spent with individual patients, whereas acute care NPs spent 74% of their time with individual patients (Becker et al., 2006). This finding is consistent with other studies reporting that NPs spend more time on individual patient care and less time on indirect and service-related care (American Nurses Credentialing Center, 2004; Gardner, et al., 2010). Other studies have supported the finding that NPs and CNMs are spending most of their time in direct care with patients (Holland & Holland, 2007; McCloskey, Grey, Deshefy-Longhi, & Grey, 2003; Rosenfeld, McEvoy, & Glassman, 2003; Swartz et al., 2003). There is no set formula as to how much time in direct care is “enough” or appropriate; however, direct care is a core competency and APRNs functioning in a clinical practice should spend at least some time over the balance of their role in direct care activities. This delineation of direct and indirect practice is not intended to denigrate clinical activities that occur outside the patient-nurse interface—quite the contrary. These clinical activities and functions should be recognized as influencing what happens in the interface and as having a significant impact on patient outcomes. Because these other clinical activities significantly affect patient outcomes, they must be valued by the nursing community and health care systems. In the current environment of cost containment and technological development, all activities that enhance patients' health, recovery, and adjustment are critical components of care delivered by APRNs. Ball and Cox (2003), based on a study of CNSs and NPs, found that APRNs engage in a range of strategic activities, an excellent characterization of the direct and indirect but adjacent actions that make up the clinical practice of APRNs as depicted in exemplars throughout the chapter. Researchers are beginning to understand the specific activities that constitute the direct care component of various advanced practice nursing roles. However, it is difficult to make generalizations about these activities because the APRNs in the studies noted previously had different roles and worked in different settings, with different populations. Different classification schemas were used to categorize APRN actions. For example, in some studies, investigators used the term activities to classify APRN actions; in others, the term interventions was used. The variability in terminology and definitions makes it difficult to compare results across APRN roles, settings, and populations. Nevertheless, a review of these studies yields some insights into the extent and nature of direct care activities in APRN roles. Many direct care activities performed are similar across APRN roles, and preparation of all APRNs must include the “three Ps”— advanced pathophysiology, advanced health and physical assessment, and advanced pharmacology (AACN, 2011). Additional direct care activities that are similar across roles include patient and family education and counseling, ordering laboratory tests and medications, and performing procedures (Becker et al., 2006; Verger et al., 2005). Verger and colleagues (2005) surveyed pediatric critical care NPs regarding their direct care activities, which included physical assessments, patient and family teaching, and performing procedures such as venipuncture, intravenous line insertions, lumbar punctures, feeding tube placements, endotracheal intubations, and central line placements. CNMs reported expansion of their direct care procedures to include first-assisting during cesarean sections and performing endometrial biopsies (Holland & Holland, 2007). CNSs and administrators need to have ongoing monitoring of the direct care components of the CNS role. With increasing complexity and diversity of the role, there is a propensity to have CNSs perform less and less expert direct care of patients, which is the main characteristic of APRN practice (Lewandowski & Adamle, 2009). Regardless of the population being cared for, surveillance was a key direct care activity of APRNs identified in studies (Brooten, Youngblut, Deatrick, Naylor, & York, 2003; Brooten et al., 2007; Hughes et al., 2002). Surveillance is described as watching for physical and emotional signs and symptoms and monitoring dressing and wound care, laboratory results, medications, nutrition, response to treatment, and caregiving and parenting. Thus surveillance refers to an APRN's vigilant assessment of patient status, the rapid diagnosis of subtle or emergent conditions, and quick intervention to prevent or reverse a potentially negative outcome. Nursing surveillance can have a particularly important impact on the patient safety indicator of failure to rescue—situations in which providers fail to notice symptoms or respond adequately or swiftly to clinical signs, resulting in patient death from preventable complications. Failure to rescue has been linked to nursing surveillance; for example, the higher the nursing surveillance, as defined by staffing ratios, the lower the number of cases of failure to rescue (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Clarke & Aiken, 2003). A study by Shever (2011) has also supported the concept that patients who receive higher surveillance, as documented by nursing in the electronic health record, are less likely to be involved in a failure-to-rescue situation. In summary, direct care activities make up a large part of what most APRNs do, although there is considerable variation in which activities are performed and how much time is devoted to the direct care function across roles, settings, and patient populations. Six Characteristics of Direct Clinical Care Provided by Advanced Practice Nurses APRNs function in many roles and settings, and with different populations. Despite such variability in role implementation, there is a similarity in the components of direct care provided. Characteristics of advanced practice nursing care extend across advanced practice roles, health care settings, and populations of patients. These six characteristics are: • Use of a holistic perspective • Formation of therapeutic partnerships with patients • Expert clinical performance • Use of reflective practice • Use of evidence as a guide to practice • Use of diverse approaches to health and illness management Accumulating evidence supports these features of APRN practice as having positive influences on patient outcomes. Throughout this chapter, the empirical evidence cited about APRN practice is illustrative and not based on a systematic review of research. The six characteristics of APRN direct care practice have their roots in the traditional values of the nursing profession. These values are defined in nursing's social contract with society, as outlined by the American Nurses Association (ANA, 2010, p. 6): • People manifest an essential unity of mind, body, and spirit. • People's experiences are contextually and culturally defined. • Health and illness are human experiences. The presence of illness does not preclude health, nor does optimal health preclude illness. • The relationship between the nurse and patient occurs within the context of the values and beliefs of the patient and nurse. • Public policy and the health care delivery system influence the health and well-being of society and professional nursing. • Individual responsibility and interprofessional involvement are essential. Nurses in advanced practice roles often have a deep commitment to the values on which these characteristics rest and are able to advocate persuasively and incorporate these values in daily practice. The expanded scope of practice of APRN roles often enables APRNs to fully enact these characteristics in their interactions with patients. An overview of strategies for enacting these characteristics is provided in Box 7.3. Box 7.3 Characteristics of Advanced Direct Care Practice and Strategies for Enacting Them Use of a Holistic Perspective • Take into account the complexity of human life. • Recognize and address how social, organizational, and physical environments affect people. • Consider the profound effects of illness, aging, hospitalization, and stress. • Consider how symptoms, illness, and treatment affect quality of life. • Focus on functional abilities and requirements. Formation of Therapeutic Partnerships With Patients • Use a conversational style to conduct health care encounters. • Optimize therapeutic use of self. • Encourage the patient, and family as appropriate, to actively engage in decision making. • Look for cultural influences on health care discourse. • Listen to the indirect voices of patients who are noncommunicative. • Advocate the patient's perspective and concerns to others. Expert Clinical Performance • Acquire specialized knowledge. • Seek out supervision when performing a new skill. • Invest in deeply understanding the patient situations in which you are involved. • Generate and test alternative lines of reasoning. • Trust your hunches—check them out. • Be aware of when you are time-pressured and likely to make thinking errors. • Consider multiple aspects of the patient's situation when you are deciding how to treat. • Make sure that you know how to use technical equipment safely. • Make sure that you know how to interpret data produced by monitoring devices. • Pay attention to how you move and touch patients during care. • Anticipate ethical conflicts. • Acquire technology-related skills for accessing and managing patient data and practice information. Use of Reflective Practice • Explore your personal values, belief systems, and behaviors. • Identify your basic assumptions about health care, the advanced practice registered nurse role, and the rights and responsibilities of patients. • Consider how your assumptions affect your judgments. • Talk to colleagues and your teachers about your clinical experiences. • Consider use of a journal to document experiences. • Assess your current skill and comfort in reflection. Use of Evidence as a Guide for Practice • Learn how to search health care databases for studies related to specific clinical topics. • Read research reports related to your field of practice. • Seek out systematic revision of research and evidence-based clinical guidelines. • Acquire skills in appraising the various forms of evidence. • Work with colleagues to consider evidence-based improvements in care. Diverse Approaches to and Interventions for Health and Illness Management • Use interpersonal interventions to guide and coach patients. • Acquire proficiency in new ways of treating and helping patients. • Help patients maintain health and capitalize on their strengths and resources. • Provide preventive services appropriate to your field of practice. • Coordinate services among care sites and multiple providers. • Acquire knowledge about complementary therapies. Use of a Holistic Perspective Holism Described Holism has a variety of meanings. A broad view is that holism involves a deep understanding of each patient as a complex and unique person who is embedded in a temporally unfolding life. The holistic perspective recognizes the multiple dimensions of each person —physiologic, social, emotional, cognitive, and spiritual—and that the relationships among these dimensions result in a whole that is greater than the sum of the parts. People are in constant interaction with themselves, others, and the environment and universe and exhibit maximum well-being when all parts are balanced and in harmony (Erickson, 2007); this state of well-being can exist whether there are physical disorders or not. This comprehensive and integrated view of human life and health is considered in the health care encounter within the context of the full range of factors influencing patients' experiences (Box 7.4). Clearly, high-tech care environments with many health care providers, each focused on a particular aspect of a patient's condition and treatment, require coordinators who have a comprehensive and integrated appreciation of the patient and his or her experience of care as a whole. APRNs' capacity to keep the pieces together and promote continuity of care in a way that focuses care on the unique individual is undoubtedly why many clinical programs have an APRN member or coordinator (see “Management of Complex Situations” later). Interprofessional team members caring for older adults view the APRN as a leader in facilitating holistic care (Cowley, Cooper, & Goldber, 2016). In addition, APRNs practicing in palliative care demonstrate practice at an advanced level by combining holistic care with treatment interventions to ameliorate symptoms, all while they are evaluating the care from a system context in terms of appropriate use of resources (George, 2016). The Shuler Nurse Practitioner Practice Model is based on a holistic understanding of human health and illness in older adults that integrates medical and nursing perspectives (Shuler, Huebscher, & Hallock, 2001; see Chapter 2). Box 7.4 Factors to Consider When Helping the Patient Holistically • Patient's view of his or her health or illness • Patterns of physical symptoms and amount of distress they cause • Effect of physical symptoms on the patient's daily functioning and quality of life • Symptom management approaches that are acceptable to the patient • Life changes that could affect the patient's physical or psychological well-being (e.g., relationship changes, job change, intrafamily conflict, retirement, death of a loved one) • Context of the patient's life, including the nuclear family unit, social support, job responsibilities, financial situation, health insurance coverage, responsibilities for the care of others (e.g., children, chronically ill spouse or partner, older parents) • Spiritual and life values (e.g., independence, religion, beliefs about life, acceptance of fate) Holism and Health Assessment When working with a relatively healthy person, the APRN seeks to understand the person's life goals, functional interests, and health risks to preserve quality of life in the future. In contrast, when working with an ill patient, the APRN is interested in what the person views as problems, how he or she is responding to problems, and what the problems and responses mean to the individual in terms of daily living and life goals. In a study of 199 primary care clinical situations (Burman, Stepans, Jansa, & Steiner, 2002), NPs were found to engage in holistic assessment and ground their decision making within the context of the patient's life. In addition, NP faculty also engage students in and role-model provision of holistic care from a nursing perspective (Brykczynski, 2012). The ability to function in daily activities and relationships is an important consideration for patients when they evaluate their health, so it is an appropriate and essential focus for holistic, person-centered assessment. Most functional assessment formats focus on the following: (1) how patients view their health or quality of life; (2) how they accomplish self-care and household or job responsibilities; (3) the social, physical, financial, environmental, and spiritual factors that augment or tax their functioning; and (4) the strategies that they and their families use to cope with the stresses and problems in their lives. In pediatrics, measures of functional status have been developed, such as one for children with asthma (Centers for Disease Control and Prevention, 2013). In adults, APRNs may choose to use a disease- or problem-focused tool such as measurement of functional status in heart failure patients (Rector, Anand, & Cohn, 2006), of symptom distress in cancer patients (Chen & Lin, 2007; Cleeland et al., 2000), or of function and disability in geriatric patients (Denkinger et al., 2009), or a widely used general measure such as the Short Form-36 Health Survey (SF-36), which measures overall health, functional status, and well-being in adults and is available in several languages (Ware & Sherbourne, 1992). Nursing Model or Medical Model As APRNs have taken on responsibilities that were formerly in the purview of physicians, some have expressed concern that APRNs are being asked to function within a medical model of practice rather than within a holistic nursing model. This concern is raised when APRNs function as substitutes for physicians. However, there is evidence that a nursing orientation is an enduring component of APRN practice, even when medical management is part of the role (Brykczynski, 2012; Cowley, Cooper, & Goldberg, 2016; George, 2016; Mason, Jones, Roy, Sullivan, & Wood, 2015; Box 7.5). Activities described in these studies clearly reflect a nursing-focused practice. Box 7.5 Nursing-Focused Advanced Practice Interventions • Engagement of patients in their own care • Patient education • Guidance and coaching • Care planning and care coordination • Physical and occupational therapy referrals • Use of communication skills • Promotion of continuity of care • Teaching of nursing staff • Advance directive discussions • Wellness and health promotion intiatives Statements from professional organizations indicate that APRNs value both their nursing orientation and their medical functions. For example, the description of APRNs in the ANA's nursing social policy statement includes strong endorsement of specialized and expanded knowledge and skills within the context of holistic values (ANA, 2010). On the theoretical front, several models of advanced practice blend nursing and medical orientations (see “Shuler's Model of NP Practice” and “Dunphy and Winland-Brown's Circle of Caring: A Transformative, Collaborative Model” in Chapter 2). Formation of Therapeutic Partnerships With Patients The Institute of Medicine (IOM) has recommended patient-centered care as the foundation of safe, effective, and efficient health care (Committee on Quality Health Care in America, IOM, 2001). The person-centered, holistic perspective of APRNs serves as the foundation for the types of relationships that they cocreate with patients. APRNs are well prepared to develop therapeutic relationships as the cornerstone of patient-centered care (Esmaeili, Cheraghi, & Salsali, 2014; Kitson, Marshall, Bassett, & Keitz, 2012). The Gallup Poll has consistently reported that the public views nurses as the most trusted professionals (ANA, 2016). The skill of APRNs to develop therapeutic relationships with individual patients can influence broader public perceptions. The development and maintenance of therapeutic relationships with patients and families is one of the key criteria in The Essentials of Doctoral Education for Advanced Nursing Practice (DNP Essentials), which is specific and foundational to advanced practice nursing (AACN, 2006). Studies have shown that APRNs form collaborative relationships with patients. In research of an APRN-directed transitional care model (Bradway et al., 2012), the authors found that a mutually trusting relationship between the APRN, the cognitively impaired patient, and the caregiver was key to providing the caregivers with the confidence and information they needed to optimally care for their loved one. This personal relationship and the availability of the APRN outside routine visits led to the avoidance of potentially negative outcomes. The APRNs utilized their advanced skills in tailoring information to improve caregiver skills and knowledge in these complex patient cases. Bissonette, Woodend, Davies, Stacey, and Knoll (2013) also found that an APRN-led collaborative team led to fewer emergency department visits and hospital admissions in kidney transplant recipients. In addition, Drennan et al. (2011) found that patients were satisfied with their relationships with nurses and midwives, including the consultation process, patient education, medication advice, and the patient's intent to comply with provider advice. APRNs' therapeutic use of self contributes to the optimization of a therapeutic relationship with patient and family. Therapeutic use of self involves APRN awareness of personal feelings, attitudes, and values and how that awareness influences the patient-provider relationship (Warner, 2006). This increased awareness on the part of the APRN helps increase empathy, allowing the APRN to engage more deeply with patients while maintaining appropriate boundaries to maintain objectivity (Warner, 2006). See Exemplar 7.2 for an example from a patient perspective when a therapeutic partnership is not established. Exemplar 7.2 A Cautionary Tale: The Founder of the First Nurse Practitioner (NP) Program on Disappointing NP Encounters Dr. Eileen O'Grady interviewed Dr. Loretta Ford, the founder of the NP role, on February 16, 2016. The following discussion captures a not-so-exemplary experience she had seeing a NP who did not meet her needs or appear to be practicing even the most basic nursing skills. This is presented as a cautionary tale about how patients can experience APRNs who do not embody the seven competencies. Dr. O'Grady: I'd like to start with an incident you had a few years ago, seeing a NP who fell short of meeting your needs. Dr. Ford: I ended up with a NP from the cardiologists' office. [The cardiologist] called himself the electrician of the cardiac team because he puts in the pacemakers. I began to have tachycardia attacks that were unusual, so I made an appointment but the cardiologist was busy, so they said I could see the NP. So, I said “Fine!” That was good. I was on some medications and I felt they needed to be changed but when I checked them out, I was taking the maximum dose, so I didn't want to increase it until I had some information about it. So, I went to see the NP. I hadn't seen her before and she came in and said her name; when I go to any health service I never tell them who I am or what my background is or anything. I'm careful not to use any technical language that might give me away. Right away there didn't seem to be any interest in me as a person, and so of course I didn't say anything. I didn't want to give it away, but I also didn't offer anything. First of all, there was no history of any kind taken, not even a nursing history. There was no asking. She was looking at the computer more than at me and asking the computer “Now, is this unusual, this recent event?” or “What triggered it?” She never asked what I thought might trigger it. So from there on, it lacked human interaction. I could see no evidence of whether she cared or not or whether or not there was any nursing presence at all. I didn't feel that there was any caring or compassion, it was purely technical. As a matter of fact, the NP was not as caring as my primary care physician. There was no sense of coordination, and in the end she said “Well, I'll have to go and check with the cardiologist about new medication or different medication.” And that ended the visit. So, I didn't feel that nursing was there at all. I didn't think it was even good medicine myself, but I'm used to having a primary care physician who is an excellent clinician and a good teacher. So, I was disappointed, and I was never really sure if my primary care physician was consulted. I don't want any special treatment Dr. O'Grady: So, the founder of the NP role has to do her own care coordination and sees an NP who does not appear to inhabit any of nursing's core values. What needs went unmet in that exchange? Dr. Ford: Well, I'd like some human interaction, that the NP would indeed acknowledge that I was in the room instead of the computer. Now this is, in a way, an isolated incident, but it was repeated when my husband was in a rehabilitation center. The NP talked a little bit to me, but not much, and not to my husband, who didn't hear well anyway. So, it wasn't too different in that situation either. When I talk to my colleagues around the country, they have reported the same thing in terms of their experiences, so I don't know that this an isolated incident, but it seems to be the experience of nurses as patients around the country. Secondly, my daughter has been cared for by another NP, and it's been phenomenally good. The coordination was excellent, the caring and communication for her worked out beautifully because she's finally had somebody to listen to her. So, you don't want to condemn all the NPs from my experience, but it's interesting how variable it is and I don't know if its preparation or system problems. But certainly there's no legal restriction against practicing basic nursing care, the possibilities of nursing are so vast, in terms of patient care. Dr. O'Grady: But this failure that you and your colleagues have experienced. What would you say is driving that? Where is the failure? Dr. Ford: Well, I think there are failures in the systems controls. Some of the states are racing to the bottom as far as legal authorization for APRNs is concerned. But that shouldn't keep people from practicing basic nursing skills: caring, compassion, care coordination, teaching, and learning. After all, those nurses, many of them are practicing with specialists and know a great deal, and they ought to use that in teaching patients. None of us experienced that, those of us who haven't had a good experience seeing NPs as nurse patients. On the other hand, I think the system has failed because in a sense the rewards are not there either. Rewards that they sometimes experience, is when they identify an unusual disease entity. It is a system that doesn't reward NPs with recognition, respect, or remuneration. Then of course you have to ask about their preparation. A lot of people don't know the history of the NP; they're not interested in history, they're interested in what's going on today and tomorrow. And of course, once you take history out of the curriculum, you “integrate” it. Well, I say that integration means it's out of the curriculum. Because, all they know about is Florence Nightingale, but they don't know all of the things that Florence Nightingale encompassed as basic tenants of nursing. Dr. O'Grady: So, given this disappointing NP experience, does your vision for the nurse practitioner future differ from what it was in the 1960s? Dr. Ford: It does, because frankly the role has been increasingly medicalized. In that sense, the system is changing in prevention and promotion. We had four elements really: prevention, promotion, preservation, and protection. Henry [Silver] and I had many discussions about the language that we were using. We didn't call it physical exam; I insisted we call it physical assessment, because that is a nursing word. We have to keep nursing in the language and in concept, and to use the forward-looking concept of interdependence. So that nurses were independent in nursing, but not independent in teams. Everyone was interdependent in the team care. But the elements of nursing came right out of nursing. Because if you read the early literature, nursing was developing as a profession, and NPs needed to be independent in nursing, that it's health and wellness oriented and that the involvement of the patient as a member of the team is vital. That the nurse and the patient and others on the team were actually partners, and that's where many of the teaching elements came in. So it was built on what the profession was saying at the time and we even used the nursing process; assessment, implementation, evaluation was part of what we were doing. And when we went to the state boards, we laid it out. That was the goal. Dr. O'Grady: So how is your vision different today than it was in the 1960s for the future? Dr. Ford: I think, for example, we're talking about nurses substituting for the primary care deficits of medicine. Well, I don't see that! I see them as being able to offer services to patients, regardless of their disease entity, with regards to health and wellness. How they cope with their illness, prevention. I mean, it was built on primary, secondary, and tertiary prevention of caring. And that could include adjusting medications; it has always involved medications, but not to the extent it does today. You know, we have made the cardinal error of developing legal authority by going after it task, by task, by task. It was the worst strategy and I never agreed with that because every time you turned around, we were running to the legislature to order equipment, to give certain scheduled drugs. Next thing you know, we'll be asking the legislature to allow us to pluck eyebrows, and that's ridiculous! So we've in some way painted ourselves into a corner by these efforts. I've realized that creating one role (like the NP) was not going to change the system. The system was so strongly medically controlled. It's always one of these three things: power, control, and money. And you see them being played out every time, in every element, in every state: power, control, and money. Dr. O'Grady: So, what could you say to a graduate student who's reading this book and doesn't want to become the NP who is not really assessing anything, not really being caring, not connecting. What would you say to that NP when working in this metric-driven delivery system, that doesn't value these other things, these nursing things? What could the NP do? Dr. Ford: Well, in the first place, I think the NP ought to select the place of employment very carefully, and negotiate ahead of time what she has to offer and find out what they don't have and say: “I cannot do what you don't have. You don't have physicians; you want physicians? Don't ask me. That's not what I do. Let me tell you what I do.” In that way, in Colorado by the way, there is a good example of this. I worked with a man who was a specialist and the best that ever happened is that I was a generalist in both pediatrics and family care (because I was a public health nurse). And we were a perfect match because he did what he did in medicine and I did all the family work and all kinds of things that made a difference in the outcome of the patients' wellness and health and living. So, you don't need to be a specialist duplicate of what the specialist is. You need to be doing the thing that you can do best as a nurse. This doesn't mean that you shouldn't know a lot about what the specialist does and what the treatments are, and be able to adjust them to meet that patient's particular environment and experience. So it seems to me that you need to negotiate ahead of time, in terms of what you can and can't do and won't do—not because you can't do them, but because they're not where you want to spend your time. Dr. O'Grady: So, it almost sounds like staying in your lane. Doing what you do really well. Dr. Ford: Well, that will change. Because things change. For example, the technology is changing so rapidly today that we have to change with it, or we have to invent it. We should not be flippant all the time of these inventions. And it doesn't need to be technology, but technology that we have at hand. Different ways and things to think about asking: “Why are we doing this? Do we really need to do it or does it matter?” I think we're in a time-warp in a sense. Dr. O'Grady: So before we end, is there anything parting that you'd say about this whole incident or incidents that you've had with your husband and the NPs? Is there any parting advice or solution? Dr Ford: Well, I think reflective practice has yet to come into being, so you must look at what you're doing every day and how you're spending the day. And it must include reflection on the interactions you are having with patients. Really know what a professional model of nursing is, and talk with others about it. Really talk with and listen to the patients. The listening has gone out the window you know. Dr. O'Grady: Well, I'm writing the policy chapter and we are seeing the lay of the land and scope of practice for APRNs is moving at such a glacial place. The Affordable Care Act has largely decentralized decision-making and so the governance of delivery systems will dictate how APRNs get paid and how they're involved. So, there are just many more tables to be at. It's harder to influence because it's a one-by-one. Dr. Ford: Well there's no doubt that there's going to be some changes in the air but as I say it's power, control, and money. But I'm sure that when I'd talk about independent practice, I'd sure talk about it in terms of the statutory authority. Because the states, anything in fact that raises such flags, and no one is independent, we're all interdependent. Shared Decision Making In addition to eliciting information that increases understanding of the patient's illness experience, APRNs, in the studies cited, encourage patients to participate in decisions regarding how their diseases and illnesses should be managed. There is a continuum of patient involvement in making decisions for her or his own health care. At one end of the continuum are patients who want to be fully engaged in a partnership with providers in making decisions, whereas at the other end of the continuum are patients who want to rely on family members or care providers to make all treatment decisions. This may include patients who are older, sicker, or cognitively impaired, or who have cultural beliefs that lead them to defer decisions to others. In general, patients express interest in wanting to be more involved in care planning and treatment decisions, and it is increasingly being demonstrated that with increased involvement, particularly in patients with chronic illness, there are improvements in individual care and outcomes and improved adherence to recommended regimens (Houlihan, 2015; Kitson et al., 2012; Kullberg, Sharp, Johansson, & Bergermar, 2015; Robinson, Callista, Berry, & Dearing, 2008). No matter where the patient falls on this continuum, it is still incumbent on the provider to establish a collaborative partnership to ensure that regardless of whom the patient wants to make decisions, it is done in congruence with the patient's beliefs and values (Esmaeili et al., 2014). APRNs should individually determine each patient's preference for participation in decision making and be sensitive to the fact that patients' preferences may change over time as they get to know the provider better and as different types of health problems arise. Once the patient's preference has been elicited, the provider should tailor his or her communication and decision-making style to the patient's preference. Many patients have not had prior health care experiences in which shared decision making was even a possibility but, when offered the opportunity, many choose it—tentatively in some cases, enthusiastically in others. Trying on a more active role may require some help from the provider, such as explaining how it would work and which responsibilities are the patient's and which are the provider's. Providers can encourage patients to bring up issues by asking open-ended questions such as “How have you been?” and focused but open questions such as “How are things going at home?” Patients can be encouraged to participate in decision making by offering them explicit opportunities in the form of questions such as “Does one of those approaches sound better to you than the other?” Gradually, patients approached in this way will learn that health care encounters will be organized around their concerns, not around a series of questions asked by the provider, and that they should feel safe to express their concerns and preferences. Open and honest communication is foundational to a shared decision-making philosophy. APRNs have reported more advanced communication skills than those reported by basic RNs (Sivesind et al., 2003). The ability to adapt communication styles is a needed skill of APRNs (McCourt, 2006) and can result in patients reporting that they have more knowledge, confidence, and control of their own care (Esmaeili et al., 2014). It is a skill that is necessary for an APRN to maintain a therapeutic relationship with a patient while also supporting her or him in effective decision making. The APRN needs to use an approach that incorporates verbal and nonverbal behaviors exhibited by the patient while being careful to maintain professional boundaries (Elliott, 2010). APRNs must be cognizant of their own personal beliefs and value systems in a partnership in which they are coaching patients in decision making (see Chapter 8). Although they are uniquely prepared to facilitate the holistic management of the physical, psychosocial, and spiritual aspects of care in these particular situations, APRNs may be involved in interactions in which it is difficult for them to help patients make decisions. If the APRN is unaware of or has unresolved issues of his or her own, he or she may risk exercising undue or unintentional influence on a patient's decision in emotionally charged situations. Bringing one's own beliefs and values to consciousness prior to a discussion focused on patient decision making, reflecting on one's own cognitive and affective responses to such discussions, and debriefing with a colleague can help APRNs maintain a therapeutic approach (or determine when it is appropriate for another clinician to become involved). Cultural Influences on Partnerships Another important factor affecting whether and how persons want to participate in health care decision making is their cultural background. It is easy to forget that not all cultures value individual autonomy as much as North Americans of Anglo-Saxon ancestry. Increasingly, recognizing and respecting the cultural identification of patients is being viewed as essential to building meaningful partnerships. Cultural groups form along lines of racial, national origin, religious, professional, organizational, sexual orientation, or age group identification. Some cultural groups are easier to identify than others. Physical differences in appearance may indicate to the provider that he or she is dealing with a person of a different cultural orientation. Other cultural identifications are less obvious—for example, people with religious beliefs about fate, God as healer, or treatment taboos. However, it is important to avoid making assumptions about cultural beliefs simply based on physical appearance or dress. In today's increasingly diverse society, many families have blended traditional beliefs and practices from a number of cultures. These beliefs are learned by asking the patient open-ended questions and responding in a way that makes the patient feel understood. The DNP Essentials identifies the need for APRNs to synthesize and incorporate principles of cultural diversity into preventive and therapeutic interventions for individuals and populations (AACN, 2006). The preparation of APRNs in the area of cultural competence and culturally appropriate care is key because the demographics of nurses, including APRNs, do not match the overall demographics of the US population (Budden, Zhong, Moulton, & Cimiotti, 2013; Murray, Pole, Ciarlo, & Holmes, 2016). Interactions that are complicated by cultural misunderstandings can result in incomplete or inaccurate assessments and even in misdiagnoses and suboptimal outcomes (Barakzai, Gregory, & Fraser, 2007; Nokes, 2011; Sobralske & Katz, 2005). The APRN needs to individualize care based on an assessment of the cultural influences on the perception of illness and reporting of symptoms. Otherwise, differences in perceptions can cause confusion, misunderstandings, and even conflicts that disrupt the patient-provider relationship and discourse. Moreover, cultural influences often complicate attempts to resolve misunderstandings because different cultural groups approach conflict negotiation differently. Studies have shown that NPs can engender trust in a population such as African-Americans to an equal or greater extent than physicians (Benkert, Peters, Tate, & Dinando, 2008; Peters, Benkert, Templin, & Cassidy-Bushrow, 2014). In every encounter, the provider should expect that the patient may have values that are different in some ways from his or her own and must make a special effort to ensure that the care being given meets the patient's needs and is acceptable to him or her (Escallier & Fullerton, 2009). APRNs must always remain nonjudgmental and not impose their own beliefs or biases onto the patient. Communication With Patients A foundation of good communication with patients is essential to developing a therapeutic relationship. Research has shown that good communication between the APRN and patient can increase patient satisfaction, establish trust, increase adherence to a treatment plan, and improve patient outcomes (Bentley, Stirling, Robinson, & Minstrell, 2016; Burley, 2011; Charlton, Dearing, Berry, & Johnson, 2008; Gilbert & Hayes, 2009; Kinder, 2016; Persson, Hornsten, Wirkvist, & Mogren, 2011). Learning good communication skills takes ongoing practice throughout the APRN's career. Options for doing this include using standardized patients and simulation laboratories with feedback, which have been shown to improve APRN students' interpersonal and communication skills (Kesten, Brown, & Meeker, 2015; Lin, Chen, Chao, & Chen, 2013; Pittman, 2012; Rosenzweig et al., 2008). One aspect of optimal communication is listening. Listening has been described as being fully present with the patient to garner patient details, increase the level of trust in the relationship, and improve patient compliance (Browning & Waite, 2010). Listening takes as much concerted effort to perform optimally as verbal communication. Key to good listening is the ability on the APRN's part to avoid being distracted by personal thoughts, forming instant judgments, and formulating a reply while the patient is still speaking and telling her or his story. In addition, the APRN must become aware of how individual expectations, experiences, and cultural paradigms can result in biases and misperceptions when working with patients (Browning & Waite, 2010). Reflective listening techniques can be useful when APRNs convey to patients that they have been heard and understood without judgment and can assist patients in exploring their personal situations more fully (Resnicow & McMaster, 2012). These techniques include taking patient statements and restating, rephrasing, reframing, and reflecting thoughts, feelings, and emotional undertones back to the patient (Miller, 2010). Therapeutic Partnerships With Noncommunicative Patients Some patients are not able to enter fully into partnership with APRNs because they are too young, have compromised cognitive capacity, or are unconscious. Examples of clinical populations who may be unable to participate fully in shared decision making are listed in Box 7.6. Unfortunately, staff nurses working with noncommunicative patients can become so focused on providing care that they forget about having meaningful interactions with the patient (Alasad & Ahmad, 2005). APRNs can role-model alternative forms of communication so that noncommunicative patients can receive optimal care. Box 7.6 Patient Populations Unable to Participate Fully in Partnership • Infants and preverbal children • Anesthetized patients • Unconscious or comatose patients • People in severe pain • Patients receiving medications that impair cognition • People with dementia • People with psychiatric conditions that seriously impair rational thought • People with conditions that render them incapable of speech and conversation • People with congenital or acquired cognitive limitations • People whose primary language is different from the provider's Although these patients may have limited ability to speak for themselves, they are not entirely without opinion or voice. Situations in which patients will experience temporary alterations in cognition or verbal ability can often be anticipated. For example, in planned perioperative situations in which general anesthesia and intubation will be used, the CRNA has the opportunity to dialogue with the patient prior to the procedure. This creates a shared relationship in which the patient can feel comforted and confident about the upcoming procedure (Rudolfsson, von Post, & Eriksson, 2007). The CRNA can prepare patients for the period when communication will be a challenge and propose alternative methods for communication. In addition, the CRNA can discuss patients' preferences for handling possible events beforehand to elicit their wishes. In the absence of this type of prior dialogue, experts who work with patients who cannot verbalize their concerns and preferences learn to pay close attention to how patients are responding to what happens to them; facial expressions, body movement, and physiologic parameters are used to ascertain what causes the patient discomfort and what helps alleviate it. In a study of persons who had experienced and recovered from unconsciousness (Lawrence, 1995), 27% of the patients reported being able to hear, understand, and respond emotionally while they were unconscious. These findings suggest that nurses should communicate with unconscious patients by providing them with interventions such as reassurance, bodily care, pain relief, explanations, and comforting touch. There are tools that can be used for patients who are conscious but unable to communicate. Unfortunately, many nurses are not adequately educated in using alternative methods of communication and, if they are, may not be familiar or comfortable with the particular method required for an individual patient (Markor & Hazan, 2012; Thompson & McKeever, 2014). Other barriers include not having access to communication devices and time pressures that may not allow providers to engage adequately in a process that could take more time. Other sources of information about patients who are unable to respond physically or to communicate should also be identified. For example, siblings visiting an adolescent male with a major head injury would be able to tell you what type of music he likes to listen to and could even bring you a playlist to play for the patient. His mother would know what has caused him to have skin reactions in the past. Responding to his father's offhand comment that he cannot stand to be without his glasses when he is not wearing his contact lenses would most likely help father and son. All of these are ways of building a partnership with an unconscious teenager in an intensive care unit. In adults and adolescents, advance directives, heath care proxy documents, and organ donation cards are other sources of information regarding patients' wishes. Thus noncommunicative patients are not without voices, but hearing their voices does require presence and attentiveness, and establishing a relationship. Box 7.7 summarizes options for the APRN when engaging with noncommunicative patients. Box 7.7 Techniques for Communicating With Noncommunicative Patients • Maintain verbal interactions and eye contact with patient throughout care. • Explain procedures. • Monitor tone of voice to avoid inadvertently relaying emotional subcontext to the actual words used. • Use appropriate touch for reassurance. • Use other communication devices such as alphabet and word boards, writing, computers, and electronic communication devices. • Use interpreters for foreign languages and sign language. • Use other sources of information for patient's likes and dislikes —family, primary care providers, friends. • Use physiologic cues—grimacing, frowning, turning away from touch, relaxing facial muscles, blood pressure and heart rate responses—as appropriate to evaluate patient responses to care and treatments. Expert Clinical Performance Few studies have clearly differentiated between the expert skills of the APRN and the practice of the basic RN. The expert performance of an APRN encompasses clinical thinking and skills. An expert's clinical judgment is characterized by the ability to make fine distinctions among features of a particular condition that were not possible during beginning practice. Benner's (1984) studies of expert clinical judgment, although not with APRN participants, inform this discussion of APRNs' clinical expertise. Tanner (2006) has reviewed the literature regarding clinical judgment and found that it requires three main categories of knowledge. The first is scientific and theoretical knowledge that is widely applicable. The second is knowledge based on experience that fills in gaps and assists in the prompt identification of clinical issues. The final category is knowledge that is individualized to the patient, based on an interpersonal connection. Clinical judgment involves application of skills to the situation (Tanner, 2006; Victor-Chmil, 2013). Clinical Thinking APRNs' specialized knowledge accrues from a variety of sources, including graduate and continuing education, clinical experience, professional reading, reflection, mentoring, and exchange of information and ideas with colleagues within and outside nursing. The integration of knowledge from these sources provides a foundation for the expert clinical thinking that is associated with advanced direct care practice. Once an APRN has been in practice for a while, formalized knowledge and experiential knowledge become so mixed together that they may not be distinguishable to the outside observer. Illness trajectories and presentations of prior patients make an impression and come to mind when a patient with a similar problem is seen later (Benner, 1984). The expert also remembers which interventions worked and did not work in certain situations. Eventually, the expert's clinical knowledge consists of a complex network of memorable cases, prototypic images, research findings, thinking strategies, moral values, maxims, probabilities, behavioral responses, associations, illness trajectories and timetables, and therapeutic information. Thus experts have extensive, varied, and complex knowledge networks that can be activated to help them understand clinical situations and events. These networks are composed of internal and external resources. The APRN may mentally review internal resources such as educational knowledge, typical cases, and previously experienced cases when confronted with a complex or challenging patient. However, the APRN is also cognizant of when internal resources are no longer adequate and knows when to refer to external resources for consultation, more data, or guidance. Throughout the assessment, the APRN is using pattern recognition, deductive reasoning, and inductive reasoning to reach a differential diagnosis (Scordo, 2014). Clinical reasoning brings together the clinical knowledge of the provider with specific observations, perceptions, events, and facts from the situation at hand to produce an understanding of what is occurring (Victor-Chmil, 2013). Sometimes, the understanding is arrived at by using cognitive processes to consider evidence and alternative explanations logically. At other times, the insight or understanding arrives intuitively—that is, through direct apprehension without recourse to deliberate reasoning (Benner, Tanner, & Chesla., 1996; Tanner, 2006). In these situations, APRNs can use reflective practice to sort through the intuition to understand the components better and identify new insights. With experience, they can then repackage these insights and incorporate them into their experiential learning to use the information in the next relevant case prospectively and deliberately. Clinical reasoning can be improved through use of tools such as external verbalization (“thinking aloud”), algorithms, and reflective journaling (Victor-Chmil, 2013). APRN experts have the ability to scan a situation rapidly (e.g., past records, patient's appearance, the patient's unexpressed concern or discomfort) and identify salient and relevant information. The APRN is able to suspend judgment purposefully about personal strongly held beliefs that may be proposed by others, such as “he's a difficult patient” or “she's just drug seeking.” The ability to do this ensures as much objectivity as possible when caring for patients. For example, research has shown that expert CNSs are able to transcend the labeling of a “difficult patient” to engage in problem resolution through the use of patient respect, communication skills, and increased self-efficacy (Wolf & Robinson-Smith, 2007). Relying heavily on their perceptions, observations, and assessment skills, APRNs quickly activate one or several lines of reasoning regarding what might be occurring. They then conduct a more focused assessment to determine which one best explains the situation at hand. These lines of reasoning can be informal personal theories about the specific patient situation; this formulation draws from personal knowledge of the particular patient, personal knowledge acquired from previous experiences, and formalized domain-specific knowledge (Tanner, 2006). In implementing the solutions, these lines of reasoning can be tested by performing a clinical intervention and noting how the patient responds. Throughout this process, the APRN may be teaching and role modeling with staff to assist in staff nurse self-awareness and reflection. A novice APRN may need to work through the situation in a formal logical way and be more deliberate about the use of formal educational knowledge, enriching it over time with experiential knowledge (Tanner, 2006). It has been shown that the values and underlying knowledge a nurse brings to a situation also have a profound influence on his or her assessment of the patient. Results of one study demonstrated that a nurse's beliefs about older adults can affect how a nurse assesses the older confused patient and can affect prioritization of that patient's needs (Dahlke & Phinney, 2008). Another example is when a nurse's moral opinion of drug addiction and the interpretation of behavior as drug seeking may have more influence on the treatment of a patient's pain than does the actual assessment of the pain. If not self-aware, these potential values and perspectives may impede the APRN in making accurate diagnoses, impact determination of appropriate treatment plans, and alter the ability of the APRN to appropriately role model optimal care of patients for other interprofessional team members. Most patient accounts unfold in a fairly predictable way, and the APRN arrives at a diagnosis and/or intervention with considerable confidence in her or his clinical inferences. At other times, however, there is uncertainty and lack of understanding regarding the situation. The uncertainty may pertain to information the patient provides, the diagnosis, the best approach to management, or how the patient is responding. When there is ambiguity, experts often break into conscious problem solving or “detective-like thinking and questioning” (Benner et al., 1996; Benner, Hooper-Kyriakidis, & Stannard, 1999) to try to determine what is going on. Knowing the patient may be critical to perceptive and accurate clinical reasoning. Knowing the patient as an individual with certain patterns of responses enables experienced nurses to detect subtle changes in a patient's condition over time (Tanner, 2006; Tanner, Benner, Chesla, et al., 1993). The extent to which any nurse knows a patient may be associated with that nurse's ability to do the following: • Recognize that risk factors are present. • Detect early indicators of a problem (e.g., a subtle change in pattern). • Take timely preventive action. • Recognize nonfitting and atypical data. Nonfitting data suggest to experts that they need to generate new or additional hypotheses because the current observations and parameters do not fully explain the clinical picture as it has been or as it should be. For example, when faced with a nonfitting sign or symptom, the nurse may generate alternative hypotheses pertaining to the onset of a complication or worsening of the disease process. Thinking Errors The clinical acumen of APRNs and the inferences, hypotheses, and lines of reasoning that they generate are highly dependable. However, as practice becomes repetitive, APRNs may develop routine responses and then run the risk of making certain types of thinking errors (Scordo, 2014). Errors of expectancy occur when the correct diagnosis is not generated as a hypothesis because a set of circumstances, in the clinician's experience or patient's circumstances, predisposes the clinician to disregard it. For example, the NP who over several years has seen an older woman for problems associated with chronic pulmonary disease may fail to consider that the most recent onset of shortness of breath and fatigue could be related to worsening aortic stenosis; the NP has come to expect pulmonary disease, not cardiac disease. Or a patient presenting with nausea and vomiting during flu season may be treated for gastroenteritis, although appendicitis is the actual condition (Scordo, 2014). Erroneous conclusions are also more likely when the situation is ambiguous—that is, when the meaning or reliability of the data is unclear, the interpretation of the data is not clear cut, the best approach to treatment is debatable, or one cannot say for sure whether the patient is responding well to treatment (Brykczynski, 1991). To avoid errors in these types of situations, experts often revert to the use of maxims (a succinct metaphor for a general truth) to guide their thinking (Brykczynski, 1989). One of the maxims that NPs use to deal with uncertain diagnoses is “When you hear hoofbeats in Kansas, think horses, not zebras.” This reminds clinicians who are about to make a diagnosis that occurs infrequently to consider the incidence of the condition in the population. Thus an older adult with respiratory problems seen in a suburban office is unlikely to have tuberculosis; pneumonia is a more likely diagnosis. Because tuberculosis is rare in the older adult population, the clinical data for tuberculosis should be convincing if that diagnosis is proposed. Poor judgment can also result from tunnel vision, overgeneralization, influence by a recent dramatic experience, premature closure (Croskerry, 2003), and fixation on certain problems to the exclusion of others (Benner et al., 1999). Faulty thinking is not the only source of error in clinical decision making. Others include inaccurate observations; misinterpretation of the meaning of data; a sketchy knowledge of the particular situation; and a faulty or outdated model of the disease, condition, or response. It is important that APRNs recognize the potential for and avoid leaping to conclusions and making snap judgments. It can become easy to allow biases to lead to premature diagnoses without fully listening to or assessing patients. The expert APRN has learned to scan data constantly and look for deviations. The ability to differentiate effectively between significant and insignificant data is needed to have safe practice. Box 7.8 presents actions that APRNs can take to prevent thinking errors. Box 7.8 Actions to Use to Avoid Thinking Errors • Listen fully to patients' concerns and descriptions of their problems. • Develop and utilize a systematic approach. • Listen to input from other providers as to their assessments and perspectives. • Use a diagnostic “time-out” to review the situation with fresh eyes. • Pay attention to intuition that points to an incongruence in data; what cannot be explained? • Avoid reliance on knowledge derived solely from rote memorization or repetition, but critically think through the source of knowing and how it relates to the individual patient. • Remain constantly open to reevaluation of working diagnoses and treatments; avoid premature closure. • Be aware of personal biases and assumptions. • Continually evaluate what is “critical” data in each patient case. Time Pressures Regardless of setting, practitioners worry about the effect that time pressures have on the accuracy and completeness of their clinical thinking and decision making. A galvanizing report on errors and patient safety cited studies in which between 3% and 46% of hospitalized patients in the United States were harmed by error or negligence (Kohn, Corrigan, & Donaldson; Committee on Quality Health Care in America, IOM., 2000). It was estimated that more than 100,000 patients die from medical errors, and a more recent study suggested that little progress has been made in the decade following publication of the Kohn et al. report (Wachter, 2010). A heavy workload is associated with feelings of pressure, being rushed, cognitive overload, and fatigue adding to already burdened clinicians; these feelings clearly contribute to unsafe acts and omissions in care (Kohn et al., 2000). Time pressures have been shown to lead to worsening diagnostic accuracy in physicians (Al Qahtani et al., 2016). Evidence also comes from studies of nurse staffing in hospitals in which fewer hours of nursing care per patient per day and less care provided by RNs were associated with poorer patient outcomes (Aiken et al., 2011; Blegen, Goode, Spetz, Vaughn, & Park, 2011; Needleman et al., 2011). Effectively addressing the issues of time pressures and insufficient hours of nursing care requires culture change, process redesign, and appropriate use of technology. The patient safety movement has led to a variety of efforts aimed at preventing errors—root cause analysis of sentinel events, improved work processes, redesign of delivery systems, use of technological aids, communication training, human factors analysis, and team building. All these factors can have significant direct and indirect effects on workload, fatigue, and time available for direct patient care. The effects of a heavy workload on patient outcomes in nonhospital settings are less well understood; thus actions to address this issue have received less attention. However, as lengths of visits or contact times are decreased or the number of patients whom practitioners are expected to see in a day is increased, it is logical to assume that the number of errors in clinical thinking will increase. Each contact requires the practitioner to reset his or her clinical reasoning process by closing out one thinking project and starting on an entirely new one. This resetting, which is done back to back often during a day, is cognitively and physically demanding. How these performance expectations affect clinical reasoning accuracy is unknown. Moreover, time pressures often get compounded by hassles, which come in the form of interruptions, noise in the environment, missing supplies, increasing time needed to interact with technology, and system glitches that make clinical data or even whole charts unavailable to providers. These hassles likely interfere with providers' ability to concentrate on what the patient is saying and disrupt their efforts to make clinical sense of a patient's account. In many settings, providers are required to multitask. They start a task but must attend to another before completing the original one. This clearly increases the risks of failure to obtain needed information, broken lines of thought, technological missteps, omissions in care, and failure to respond to patients' requests for service (Cornell, Riordan, TownsendGervis, & Mobley, 2011; Ebright, Patterson, Chalko, & Render, 2003). Studies of emergency department physicians and NPs have demonstrated that their workflow patterns have frequent interruptions, which can result in shortcuts, failure to return to the original task, increased perceptions of stress, and a potential for commission of errors (Burley, 2011; Chisholm, Weaver, Whenmouth, & Giles, 2011; Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). Admittedly, the emergency department may be an extreme example of a multitasking environment, but other settings also impose interruptions at a very high rate. An experienced APRN may be more skilled at focusing on and prioritizing tasks and quickly dismissing interruptions and extraneous information. The novice APRN, conversely, may take longer to perform tasks (allowing for more interruptions) and may need more assistance with consultations or accessing resources (Phillips, 2005). As time pressures for clinicians increase, organizational efforts to monitor for errors and potential errors and seek correction when there are system weaknesses are actions that APRNs owe patients and themselves as providers functioning in busy environments. Many patients are sensitive to the pace with which staff and providers greet them, talk with them, and do things, particularly those activities that involve verbal interaction and physical contact. Some patients respond to the fast-paced talk and hurried movements of providers by not bringing up some of the questions that they had intended to ask. Others may just get flustered and forget to mention important information; still others may become hostile and withhold information. Thus errors in the form of information omission by the patient enter the clinical reasoning and decision-making process. In summary, clinical thinking is a complex task. It involves drawing on knowledge in memory and attending to multiple sources of situational input, some of which are difficult to interpret. Often, multiple clinical issues must be addressed during a patient encounter. These complexities make clinical thinking a challenging task, even under the best of circumstances. Situational awareness—perceptions of the current environment in which the APRN is functioning—can make the APRN more cognizant of the potential for error and improve diligence to the thought process at critical junctures, such as when writing orders, when performing procedures, or during handoffs (Phillips, 2005). Ethical Reasoning Clinical reasoning is inextricably linked to ethical reasoning. Clinical reasoning generates possibilities of what could be done in a situation, whereas ethical reasoning adds the dimension of what should be done in the situation (see Chapter 13). Advances in health care and medical technology have increasingly resulted in gaps between care that is medically possible and care that is in the best interest of the patient. These gaps may be most notable when making decisions regarding withdrawing or withholding nutrition, hydration, or a treatment; when dealing with reproductive technology or human genetics; and when cost must figure into clinical treatment decisions. These situations are at high risk for becoming ethically problematic. The literature regarding how to resolve ethical issues is extensive. One approach, incorporating preventive or prospective ethical considerations into clinical thinking and decision making, makes a great deal of sense (Epstein, 2012). Rather than waiting until a conflict arises, this approach places an emphasis on preventing ethical conflicts from developing by shaping the process of clinical care so that potential value conflicts are anticipated and discussed before outright conflict occurs. APRNs can use this approach with routine encounters with patients. For example, during an encounter with a healthy patient, an APRN may be able to say, “I'd like to discuss an important issue with you while you're well so I will know how to best help you if certain situations should come up in the future.” Such issues could include pain management, advance directives, or organ donation. In addition to emphasizing early communication among the patient, significant others, and the health care provider(s) about values, preventive ethics requires explicit critical reflection on the institutional factors that lead to conflict (Epstein, 2012). An additional aspect of preventive ethics is an effort to create and preserve trust and understanding among providers, as well as between providers and patients (and their families). Thus the use of preventive ethics can be considered proactive in that it requires providers to consider how the routine processes of care foster or prevent conflicts from occurring or, at the very least, ensure that such issues are identified at an early stage. The preventive approach has the potential to avoid conflicts because clinicians integrate ethical reasoning into clinical reasoning at an earlier point in time than when a traditional, conflict-based ethics approach is used. The concept of moral distress is being recognized increasingly as an issue for all nurses, including APRNs. Moral distress is defined as knowing what the ethically appropriate action should be but encountering barriers that discourage the provider from carrying out the action (American Association of Critical-Care Nurses, 2004; Rushton, Schoonover-Shoffner, & Kennedy, 2017). This results in internal conflict that is not resolved (see Chapter 13). Laabs (2005) has found that among primary care NPs, distress is most frequently caused by patient refusal of appropriate treatment. This creates a conflict for the NPs between promoting patient autonomy and beneficence on the part of the NP, resulting in feelings of frustration and powerlessness. Some NPs changed jobs and others considered leaving advanced practice altogether. The American Association of Critical-Care Nurses (2004) has developed a model to address moral distress. APRNs can use this “four As” model to understand and work toward the resolution of distressing situations; the “four As” are the following (American Association of Critical-Care Nurses, 2004): • Ask—explore and understand where the distress is coming from. • Affirm—confirm the distress and consider one's professional obligations. • Assess—use self-awareness, reflection, and evaluation to assess barriers, opportunities, and potential consequences in preparation for action. • Action—put into place actions that will initiate resolving the distress, anticipating setbacks and ways to cope with them. Encountering these situations can feel overwhelming but can also be opportunities for an APRN to reassess her or his current beliefs and values. The APRN can use concurrent and retrospective reflection on these situations as a growth and development experience that can be used in positive proactive interventions with future patient encounters (Rushton, 2006). Skillful Performance Although the health care professions place high value on knowledge and expert clinical reasoning, it is important to keep in mind that the public values skillful performance in physical examinations, delivery of treatments, diagnostic procedures, and comfort care. Most graduate schools require students to perform a specific set of procedural skills recommended by a national specialty organization before they complete their program. However, little is known about how APRNs acquire competency in new or expanded procedural skills once they are in practice. Presumably, competency of APRNs to perform specific procedures and treatments is initially ensured through the processes that agencies use to credential and grant privileges to APRNs. After that, the responsibility for acquiring new competencies lies with the individual APRN and employing agency. When an APRN or agency recognizes that patients would receive better care if the APRN could perform a new procedure, an agreement should be reached regarding exactly which new procedure the APRN will perform, the conditions under which the procedure will be done, how the APRN will acquire the necessary skill, and how supervision will be provided during the learning period. The APRN must also be aware that refinement of the technical component is only a piece of the procedure. He or she must also understand indications, contraindications, complications, and consequences of performing the procedures (Hravnak, Tuite, & Baldisseri, 2005). Documented evidence that formal training has occurred is required for regulatory purposes. The types of skills nurses have performed have evolved over time. For example, it used to be within the physician's scope of practice (and outside the nurse's) to measure blood pressure and administer chemotherapy. With the advent of the APRN role, APRNs have acquired new performance skills when it made sense within their role and for the comfort, convenience, and satisfaction of patients. It is key for APRNs to be cognizant of the scope of their role, regulatory requirements of the states, and the reasonableness of acquiring the skill. Advanced Physical Assessment Discussion continues about what actually constitutes advanced physical assessment in the differentiation between the basic RN and APRN practice. In one survey, 99 APRNs, physician assistants (PAs), and their corresponding preceptor physicians were asked to rank the importance of 87 competencies as an advanced skill (Davidson, Bennett, Hamera, & Raines, 2004). All skills were ranked fairly high as being necessary for advanced practice care. Skills ranked highest as advanced skills were cardiac assessments, such as rhythm interpretation, and women's health skills, such as gynecologic and breast examinations. Competencies such as head, neck, and throat and skin assessment skills were rated lower on the advanced skill priority scale. The authors reported that higher rated skills appeared to need more use of clinical judgment to interpret or differentially diagnose when compared with lower rated skills, which tended to be more demonstration or technical skills. Another component of advanced assessment is the use of evidence in assessing and formatting a diagnosis (Munro, 2004). APRNs should be skilled at understanding and using the concepts of sensitivity, specificity, and the kappa statistic to differentiate the likelihood of presence or absence of disease based on physical signs and the reliability of that finding. The increased use of technology does not preclude the importance of the physical assessment in reaching an accurate diagnosis (Munro, 2004). Using advanced practice nurses as specialized standardized patients in simulations can facilitate improved clinical reasoning in APRN students (Payne, 2015). Patient Education Patient education is a central and well-documented function of all nurses in any setting, and evidence of its effectiveness has been well established (Redman, 2004). Teaching and counseling are significant clinical activities in nurse-midwifery (Holland & Holland, 2007) and CNS practice (Parry, Kramer, & Coleman, 2006). There are several examples of the role of NPs in patient education to promote adherence to treatment regimens and provide health care information to improve outcomes and quality of life (Hahn, 2014; Lerret & Stendahl, 2011; Mao & Anastasi, 2010; McAfee, 2012; Whitehead, Zucker, & Stone, 2014). APRNs must understand the basic principles of patient education and the specific educational needs of their clinical populations. The teach-back method is especially helpful in ensuring understanding by the patient of the content the APRN is teaching (Agency for Healthcare Research and Quality [AHRQ], 2015). APRNs must be aware of the research in their specialties and be responsible for knowing the theoretical and scientific bases for patient teaching and coaching in their specialties and practice settings. Students can develop competence by developing and implementing patient education. For example, a student could negotiate with a preceptor to co-lead a self-management group for patients with a chronic condition, using motivational interviewing and other chronic disease management strategies. Other activities could include developing limited literacy tools or evaluating existing patient education materials with regard to the appropriateness of content and health literacy level and evaluating the reliability and appropriateness of health information on the Internet. Consumers are increasingly using the Internet as a primary source of health care information. Students should know the health information resources likely to be used by their patient populations and be able to advise patients as to which websites are reliable and regularly updated. In the United States, only 12% of adults have adequate health literacy to be able to navigate the health care system (AHRQ, 2016) (Box 7.9). Assessment of functional health literacy must be done sensitively. Years of education completed may not be an adequate indicator of reading and computational literacy. In addition, people with higher levels of education who experience a new diagnosis or other stresses may be unable to process complex information and consequently may benefit from the use of limited literacy materials (AHRQ, 2016). A variety of tools are available to assist clinicians in assessing patient literacy (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Davis et al., 1993; Sand-Jecklin & Coyle, 2013). APRNs involved in developing programmatic approaches to patient education must ascertain that materials are appropriate to the literacy level of participants in educational programs. Educational materials should use plain language—that is, text that exemplifies clear communication (National Institutes of Health, 2012; Stableford & Mettger, 2007). Plain language text is accessible, engaging, and reader friendly. Stableford and Mettger (2007) noted that reading levels alone are insufficient to determine whether text was prepared using plain language principles. Box 7.9 Red Flags for Low Literacy • Frequently missed appointments • Incomplete registration forms • Non-adherence with medication • Unable to name medications, explain purpose or dosing • Identifies pills by looking at them, not reading label • Unable to give coherent, sequential history • Asks fewer questions • Lack of follow-through on tests or referrals From Agency for Healthcare Research and Quality. (2015). Health literacy: Hidden barriers and practical strategies. Rockville, MD: Author. Retrieved from www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacytoolkit/tool3a/index.html. Numerous resources exist to help APRNs improve their abilities to assess health literacy and prepare useful, readable instructional materials. The Harvard T.H. Chan School of Public Health (2015) website is particularly useful; it includes slides documenting the problem of health literacy and its effects on health, as well as links to numerous resources. As APRNs work to improve the quality of educational materials for patients with limited literacy, they may encounter resistance to simplifying language and educational tools (Stableford & Mettger, 2007); therefore, slides and other resources that document the extent and impact of health illiteracy may be useful. Adverse Events and Performance Errors Since the publication of “To Err is Human” (Kohn et al., 2000), medical errors have been prominent in the public eye, as well as a focus of reform for health care institutions. Ideally, institutions and care providers should focus on improving the reliability of complicated systems to prevent failures or quickly identify, redesign, and rectify failures that do occur. Improving reliability ensures that care is consistently and appropriately provided. Traditionally, institutions and providers have been reluctant to be forthcoming with patients when errors or near misses have occurred. That stance is slowly changing with the movement toward increasing transparency in care and a focus on addressing system dysfunction to improve patient safety. In 2002 the National Quality Forum (NQF) first identified a list of adverse medical events that health care systems should work to prevent and publicly report when they occur to encourage public access to information about health care performance (NQF, 2008). This list was updated in 2006 and 2011. The 29 events are categorized into seven main areas: surgical or invasive procedure events, product or device events, patient protection events, care management events, environmental events, radiologic events, and potential criminal events (NQF, 2011). The Centers for Medicare and Medicaid Services is now denying payment for some of these publicly reported events, and it is anticipated that additional events will continue to be identified for denial of payment. There are increasing resources available in clinics and health care settings to try to prevent adverse events, including computer-generated alerts for ordering medications and laboratory tests; interdisciplinary colleagues, such as pharmacists and dietitians; electronic resources to access and verify recommendations and practice guidelines; appropriate steps in patient identification; and optimal team communication techniques (White, 2012). It is critical that APRNs consistently use them and be involved in decisions related to their development. These changes are relevant to APRNs as the changes relate to their direct care role and the potential to be involved in “never,” near miss, or medical error situations. It would be to the APRN's advantage to be cognizant of the institution's or practice group's policies related to appropriate actions when errors occur and what is required to be reported publicly based on federal and state regulations. APRNs may find themselves involved in these situations as a result of the many issues discussed, such as thinking errors and time pressures. APRNs involved as providers in these types of events should anticipate the need to readily inform the patient and family of the event. Honest open communication and sensitivity will help preserve trust and support ongoing care. When errors in care happen, patients expect to receive an explanation and an apology; doing so may help preserve a trusting relationship and at least ameliorate anxiety, fear, and confusion (Leape, 2012). A consensus group of Harvard hospitals (Massachusetts Coalition for the Prevention of Medical Errors, 2006) has recommended four steps for communicating about adverse events: 1. Tell the patient what happened immediately, but leave details of how and why for later when a thorough review has occurred. 2. Take responsibility for the incident. 3. Apologize and communicate remorse. 4. Inform the patient and family what will be done to prevent similar events. APRNs should take advantage of training and educational opportunities on how to communicate bad news and ways to promote safety. In addition, APRNs involved in incidents should anticipate the need for their own emotional support during this time. Use of Reflective Practice To continually grow and develop, APRNs must be reflective practitioners. APRNs may be familiar with multiple methods of learning—didactic, small group projects, clinical experiences with preceptors—but may be less familiar with this method of learning, which will be useful to them throughout their careers. Reflective practice is a way to take the experiences a practitioner has (positive or negative) and explore them for the purpose of eliciting meaning, critically analyzing, and synthesizing and using learning to improve practice (Atkins & Murphy, 1995; Kumar, 2011; Schön, 1992). The goal is to turn experience into personal knowledge by seeking insights that are not available with superficial recall (Atkins & Murphy, 1995; Kumar, 2011; Rolfe, 1997; Schön, 1992). Research findings have shown that reflective practice by APRN students is a valuable learning method, may increase self-confidence as a practitioner, and may improve clinical decision making (Raterink, 2016). Forms of clinical supervision are frequently used in mental health nursing. Barron and White (2009) have described clinical supervision in this realm as a relationship between a more experienced and a more novice nurse in which the expected outcome is to assist the lessexperienced nurse in the professional development of knowledge, skills, and autonomy. In these cases, clinical supervision may be used as a debriefing with a trusted and more experienced colleague of a situation that has been complex, intense, or characterized by uncertainty. Reflection is not just a retrospective activity; it may occur prospectively or concurrently while providing care. Retrospective reflection occurs when an APRN takes the opportunity to consider how a situation could have been handled differently. Prospective reflection may occur when an APRN prepares to enter a difficult or uncertain clinical situation; one draws on experience and scientific knowledge to plan an approach and anticipates possible reactions or outcomes. Reflection can also occur concurrently. Concurrent reflection is termed reflection-in-action and can promote flexibility and adaptation of interventions to suit the situation. Reflection-in-action may be the goal of a more expert practitioner who has honed the skill of reflection (Benner et al., 1999). Although Benner's work was done with bedside staff nurses, it may be applicable to APRNs as well, as research by Fenton and Brykczynski (1993) suggested. Several models have been proposed to gain expertise in reflective practice (Atkins & Murphy, 1995; Brubakken, Grant, Johnson, & Kollauf, 2011; Johns, 2000; Kim, 1999), although they use similar processes to guide the practitioner through the reflective process. Deliberate self-reflection allows the APRN to anticipate alternative possibilities, remain flexible in challenging and changing situations, and strategically integrate the results of self-reflection with best practices to match interventions to patient and family needs. Strengthening skills in self-reflection can be done in a number of ways for the APRN—through solitary self-evaluation, with a supervisor or teacher, or in small groups of supportive colleagues. With experience, the APRN may be asked to be the mentor in guiding others through a self-reflective process. Regardless of which model is used for reflection, the following guidelines can be considered: • If reflection occurs in a small group, participants must feel safe to express thoughts, emotions, and thinking processes without fear of judgment. • Practitioners need to gain self-awareness of personal values, beliefs, and behaviors. • Practitioners need to develop the skills to articulate a situation with objective and subjective details. • Critical debriefing and analysis are used to identify practitioner goals in the situation, extent of knowledge that was present or missing, feelings on the part of the practitioner and patient, consequences of actions, and which alternative options existed. • Knowledge gained through this process can be integrated with current knowledge to change interventions in a current situation or improve approaches in future situations. • Evaluation of this reflective process supports masterful practice and creates lasting improvements in practice. There are several barriers to using reflection in daily practice. Lack of time may result in care and interventions becoming routine. The use of a reflective practice process will require dedicated time. If not thoughtfully arranged, it may seem to be extraneous and a “nice thing to do” rather than a necessary component to the APRN role. Acknowledging that one does not always know the right answer can be difficult for an APRN who is trying to establish a practice and role. In addition, reflection may elicit emotions that may be painful or difficult to deal with. It takes experience and skill to use reflection, which is particularly important when an APRN is very involved in a situation. Novice APRNs may need guidance in performing reflection to assist in ascertaining meaning and making connections that otherwise might be missed (Johns, 2000). Finally, some may see reflective practice discussions as official surveillance when supervisors are involved, and depending on the context (Clouder & Sellars, 2004). However, when reflective thinking is developed and incorporated into one's practice, it can be a means to demonstrate professional accountability for practice and a source of lifelong learning (Clouder & Sellars, 2004). Knowledge from reflection informs future clinical decision making, especially in those situations for which no benchmarks or best practice guidelines exist. Use of Evidence as a Guide to Practice An important form of knowledge that must be brought to bear on clinical decision making, for individuals and for populations, is the ever-increasing volume of evidence. For the nursing profession, the use of evidence as a basis for practice is more than the latest trend. (See Chapter 10) The profession has been intensively exploring and considering issues regarding the use of research since the early 1970s. Historically, CNSs have led efforts in many agencies to move toward research-based practice (DePalma, 2004; Hanson & Ashley, 1994; Hanson, 2015; Hickey, 1990; Mackay, 1998; Obrecht, Van Hull Vincent, & Ryan, 2014; Patterson, Mason, & Duncan, 2017; Stetler, Bautista, Vernale-Hannon, & Foster, 1995). They have brought research findings to the attention of the nursing staff and interprofessional teams and worked to develop the research appraisal skills of nursing staffs. With the advent of the DNP, evidence-based practice skills are seen as central to APRNs' role competency and a differentiating component to the PhD-prepared nurse, who is specifically prepared to conduct research (see Chapter 10). Identifying and locating evidence and research findings is becoming easier with improved technology and categorization. However, clinicians often do not have sufficient experience in the use of various search engines available to retrieve information from databases. APRNs could benefit from education on simple tools that could greatly increase the efficiency of their searches. APRNs in all settings engaging in an evidence-based practice project would be well served by developing a relationship with a health sciences librarian who can assist with searches, save time, and prevent the omission of relevant evidence. Evidence-Based Practice It would be ideal to have all health care delivery based on research. However, in reality, there frequently may be no research on which to base decisions. Sackett (1998) has defined evidence-based practice as the explicit and judicious integration of best evidence with clinical expertise and patient values. Using only external evidence to make practice decisions is as unacceptable as using only individual clinical expertise. Usually, when APRNs are involved in designing care for a population of patients, all forms of objective evidence should be used, including quality improvement data, data from internal databases, expert opinion panels, consensus statements, national guidelines data from benchmarking partners, and data from state and national databases (e.g., the Centers for Disease Control and Prevention). Agency-specific information, collected to pinpoint the nature of a problem, is particularly useful evidence that should be combined with the more general knowledge gained from research evidence (see Chapter 10). The process and extent of quality improvement (QI) has advanced significantly in the past few years with APRNs as QI leaders in their health care settings. Use of improved QI methods and tools and a national focus on the need to make significant changes in the care of patients provide nurses with the opportunity to identify patient care issues, evaluate the problem, and implement potential solutions in a more rapid fashion than ever before. APRNs can use QI methods such as the plan-do-study-act (PDSA) process and tools (Institute for Healthcare Improvement, 2011) and the lean principles (Lean Enterprise Institute, 2017) to lead and facilitate teams in improving care. Although QI data do not have broad generalizability and the rigor of official research, they can provide evidence for significant improvements that the APRN can implement on a daily local basis. With the increasing bombardment of evidence available in the literature and via the Internet, APRNs must develop a plan to stay abreast of and manage the deluge of information. Examples of how an APRN can do this include: reading primary research reports and summaries of research findings on a regular basis; informally evaluating the soundness of the methods; and adjusting or fine-tuning his or her own practice on the basis of credible findings. This is the form of research use in which every professional nurse should engage. It is part of staying abreast of new knowledge in one's area of clinical practice. Additionally, APRNs can subscribe to listservs, such as those from the AHRQ, that send timely summaries of emerging evidence and new national guidelines. Alternatively, an APRN could join or form an interprofessional group that meets monthly to discuss research reports on topics of mutual interest. Some APRNs keep a small notebook in which to jot down clinical issues and questions about which they are uncertain. Then they can make the most efficient use of library time to explore the evidence related to the questions of interest. Evidence-based practice is a more systematic, rigorous, and precise way of translating research findings into practice. The evidence-based practice process is used in an organization to design a standard of care for a population of patients. This process is more formal because evidence-based care will be widely used as a guide to care; therefore the scientific conclusions on which it is based must be as free of bias and error as possible. In general terms, the process involves four steps: (1) locating, evaluating, and summarizing the science; (2) translating the science into clinical recommendations; (3) strategically implementing the recommendations; and (4) measuring and reporting their impact. The recommendations may take the form of a clinical practice guideline, decision algorithm, clinical protocol, or changes in policies or procedures. Clinical Practice Guidelines Evidence-based clinical practice guidelines can be useful decisionmaking and planning aids for clinicians. Many guidelines have been developed in close association with providers, are based on systematic and thorough reviews of research evidence, and have attained a balance between optimal care and economic reality. However, contractors also use clinical guidelines to ensure quality, limit variation of care, and control resource use. Guidelines should be based on research evidence that is evaluated and summarized by a credible panel, inside or outside the system, to ensure that the guidelines serve to incorporate science into practice and contain costs. Providers involved in the care of patients with the condition that the guideline addresses should have the opportunity to adapt guidelines produced by others. Ideally, clinicians should review proposed guidelines and negotiate problematic recommendations in advance to avoid situations in which the care of the individual becomes the focus of negotiation. In addition, clinicians should acknowledge that, although the guidelines may serve most patients well, some patients will require treatment and interventions not recommended in the guidelines. An explicit method for advocating for individual needs should be available to clinicians. Guidelines can be found through organizations such as the National Guideline Clearinghouse (www.guideline.gov) and AHRQ (www.ahrq.gov), and professional organizations such as the American Heart Association. Clinicians should review published guidelines carefully and be familiar with the criteria each organization uses to grade the strength of the evidence used to make care recommendations. It is important that APRNs be part of teams that are developing new guidelines for practice. Theory-Based Practice The preceding discussion of evidence-based practice recognizes how research evidence informs practice but ignores the role of theory. APRNs are becoming comfortable with the idea of research evidence as a guide to practice, yet the idea of theory-based practice is less familiar. It should not be because, contrary to common perception, theory can be a practical tool. Theory often brings together research findings in a way that helps practice be more purposeful, systematic, and comprehensive. In the past, most discussions of theory-based practice addressed the use of conceptual models of nursing to guide care (Bonamy, Schultz, Graham, & Hampton, 1995; Hawkins, Thibodeau, Utley-Smith, Igou, & Johnson, 1993; Laschinger & Duff, 1991; Sappington & Kelley, 1996). However, more recently, emphasis has shifted to middle-range theories, which guide practice more specifically. Middle-range theories typically address a particular patient experience (e.g., living with rheumatoid arthritis) or problem (e.g., managing chronic pain); thus their range of applicability is relatively narrow. However, this narrow range allows them to be developed to address specific issues encountered in clinical practice. Schwartz-Barcott, Patterson, Lusardi, and Farmer (2002) have made a strong case for developing theories by using fieldwork so that the theories will be more closely aligned to the realities that practicing nurses encounter. Another approach to developing theories that are more specific to clinical situations is to generate a middle-range theory from one of the broader conceptual models. For example, Whittemore and Roy (2002) developed a middle-range theory describing adaptation to diabetes mellitus based on the concepts and theoretical statements of the broader Roy Adaptation Model. Middle-range theories have a structure of ideas and concepts that are more focused than general nursing theories and are more directly applicable to nursing practice (Smith, 2013). Smith and Liehr (2013) have delineated middle-range theories that have the potential for impact on clinical nursing practice. The list in Box 7.10 provides a sampling of the middle-range theories currently available to practicing nurses, and the reader can see that the topics of the theories are substantively specific, although some are more specific than others. An APRN in a particular field may find that only one or two of these theories are applicable to her or his area of practice. However, as middle-range theories are developed for other topics, APRNs will be able to use several of these types of theories to guide different aspects of practice. Box 7.10 Middle-Range Theories • Uncertainty in illness • Theory of Meaning • Self-transcendence • Symptom management • Unpleasant symptoms • Self-efficacy • Story theory • Self-reliance • Cultural marginality • Caregiving dynamics • Moral reckoning From Smith, M. J., & Liehr, P. R. (Eds). (2013). Middle range theory for nursing (3rd ed.). New York: Springer. Diverse Approaches to Health and Illness Management APRNs' holistic approach to care and their commitment to using evidence as a basis for care contribute to how they help patients. Generally, APRNs use a variety of interventions to effect change in the health status or quality of life of an individual or family and tailor their recommendations, approaches, and treatment to individual patients. Interpersonal interventions that are psychosocial in nature are frequently termed support interventions. Support interventions are somewhat distinct from educational interventions, which are informational in nature. Coaching uses a combination of support and educational strategies (see Chapter 8). There are also discrete physical actions, which are frequently categorized as nonpharmacologic and pharmacologic interventions. These distinctions are arbitrary because good clinicians craft interventions that are a combination of the various types as they seek to alleviate, prevent, or manage specific physical symptoms, conditions, or problems. Interpersonal Interventions Support is not a discrete intervention; it is a composite of interpersonal interventions based on the patient's unique psychological and informational needs. Supportive interpersonal interventions include providing reassurance, giving information, coaching, affirming, providing anticipatory guidance, guiding decision making, listening actively, expressing understanding, and being fully present. Each of these interventions can be described in terms of the circumstances for which it is indicated. For example, reassurance is indicated when a patient is experiencing uncertainty, distress, or lack of confidence; active listening is indicated when a patient has a strong need to tell his or her story. The actions that constitute these interventions are not mutually exclusive. For example, giving factual information can be reassuring, instructional, guiding, or all of these things at the same time. In practice, these interpersonal interventions are blended and APRNs may not be consciously aware of when they are doing one and when they are doing another. This is as it should be. APRNs have no need to think “Now I'm doing active listening; next I'm going to do anticipatory guidance.” Instead, APRNs interact with patients in ways that intermingle the conceptually separate interventions. This crafting of support evolves as the APRN talks with patients; infers their worries, fears, and concerns; and, without a great deal of conscious thought, acts to alleviate their distress. A patient may experience the interaction as just a good talk with the APRN or as a feeling of being understood. However, support is a complex nursing intervention that is strategically crafted and purposefully administered, and that often makes a difference in how the patient feels and acts (Exemplar 7.3). Exemplar 7.3 An Interpersonal Interventiona J.E. is a certified nurse-midwife (CNM) in a joint CNM– obstetricians/gynecologists (OB/GYNs) practice model. The seven CNMs have an independent nurse-midwife patient panel. Consultants for the CNM practice are with the seven OB/GYNs in the shared clinical office space. Patients have access to both services at the initiation of care. Patient care is coordinated and maintained in the respective patient panels. There is a formal process for patients to be seen by the alternative groups in the practice because patients are not allowed to alternate between CNM and OB/GYN provider patient panels. Transfers of care for patients who wish to have CNM care and are considered low risk are accepted in the same manner as transfers to the OB/GYNs of patients who develop high-risk complications outside the scope of the CNM practice. J.E. has an appointment to see a couple in their early 30s who are expecting their first child. In this group CNM practice, he has met Jan and Steve once previously in this pregnancy. They are very excited about the upcoming birth because they are now 37 weeks and 5 days pregnant. Jan and Steve have prepared themselves with childbirth education classes and have hired a doula to assist them in the birthing process. J.E. reviews the record and notes that Jan has had no complications during this pregnancy. Accurate dating has been established by the use of an early ultrasound, which corresponds with Jan's last menstrual period and estimated due date. Vital signs today are normal and the patient voiced no concerns to the medical assistant who did the initial intake for this routine, scheduled prenatal visit. J.E. interviews Jan, who reports she feels well and has no concerns. Jan states that she has had more issues becoming comfortable—at night with increased hip pain, having to get up and urinate frequently, with the baby moving, and with itching. J.E. asks more about the itching and Jan relates that she has been noticing it more in the last few weeks but hadn't mentioned it before. She had looked up itching in pregnancy on the Internet and discussed it with her doula, who told her that this itching (pruritic urticarial papules and plaques of pregnancy [PUPPP]) seems pretty common in pregnancy. J.E. asks Jan more questions about the itching, and she states that it is primarily on the palms of her hands and soles of her feet and only scratching seems to help. Steve relates it is getting so bad lately it's like “watching a dog with an unrelenting scratch.” Jan states that she has tried Benadryl a couple of times but it didn't help. J.E. performs a physical examination, which reveals some minor stretch marks but no notable trunk rash, as would be expected with PUPPP. There are some excoriated marks on Jan's palms because she has been rubbing her hands during the interview. J.E. recognizes that this does not appear to be a typical PUPPP presentation and believes that the itching may be a symptom of intrahepatic cholestasis of pregnancy (ICP), a potentially serious complication. J.E. relays his thoughts to Jan and Steve and tells them that he is going to order additional blood tests. He orders a complete blood count (CBC), liver function tests, and total bile acid tests. The laboratory results reveal a normal CBC but an elevated total bile acid level of 27.6 µmol/L (normal range, 0 to 7.0 µmol/L) and alanine aminotransferase level of 104 IU/L (normal range, 0 to 50 IU/L). These results confirm that the itching is related to ICP, which puts Jan at an increased risk of intrauterine fetal demise (IUFD). With confirmation laboratory data and a term pregnancy, J.E. calls Jan and informs her of the diagnosis and the need for induction of labor because of the increased risk of IUFD. She is upset and wants to have a direct conversation in the clinic to discuss if induction is really necessary. J.E. sees Jan and Steve in the clinic and provides answers to their many questions about ICP. They want to discuss alternatives to induction because they had planned for a low-intervention, spontaneous labor and delivery. J.E. reviews with the couple that ICP is associated with a substantial risk of IUFD. This risk increases as a pregnancy approaches term. He explains that induction is considered the best option with a term pregnancy because routine antepartum testing such as ultrasound or electronic fetal monitoring (EFM) is used to evaluate for a placental insufficiency disease process and does not have the specificity to predict an increased risk of IUFD in ICP. J.E. also explains that the elevated bile acids in the amniotic fluid can cause the fetus to experience a sudden cardiac death because of effects on the umbilical artery and/or the electrical activity in the fetal heart. J.E. reviews other treatment options with the couple. Using ursodiol has been effective at decreasing the level of bile acids in the maternal system in preterm pregnancies, but its use to extend pregnancies to spontaneous labor is not recommended because the risk for IUFD still remains, even with decreased maternal bile acids at or beyond term. J.E. also informs Jan that the elevated levels of bile acid are caused by a genetic enzyme deficiency that she has and are not related to anything she did or did not do during her pregnancy. Jan is crying out of fear and disappointment. J.E. reviews the couple's birth plan with them, pointing out that the desires they had expressed in their birth plan do not have to be revised at this time because of the need for induction. Although constant EFM with induction is required, the use of telemetry will not affect Jan's movement while she is in labor, nor will the use of hydrotherapy as an alternative to pharmaceutical pain management. Jan and Steve agree with the plan of induction after this consultation and arrive at the hospital with their doula, Rita. After the initiation of induction, J.E. uses this early labor period to discuss and educate Rita privately on the rationale for induction and the pathophysiology of ICP. J.E. recognizes that educating Rita is important so she can use this information with her future clients. J.E. also knows that as a member of a childbirth cooperative group, Rita is in a place to inform and instruct her doula peers that the subjective signs of increased itching of the palms of the hands and soles of the feet can be indicative of ICP, and they can advise future clients of doulas to notify their health care providers about these findings. Emily is born to Jan and Steve at 7 pounds, 5 ounces, with an 8/9 Apgar score via normal spontaneous vaginal delivery after a 16hour labor and delivery hospitalization for induction with prostaglandins and pitocin. Jan's maternal itching is resolved and total bile acid and liver function test results are returning to normal 48 hours postpartum. Baby and mother are discharged, with no additional follow-up needed for ICP, except for the increased risk of recurrence in future pregnancies. a The author gratefully acknowledges John Eads, MSN, APRN, CNM, for use of his exemplar. Therapeutic Interventions The decision about whether or not to treat a particular condition can be difficult because the practitioner is faced with several probabilities that do not all lead to the same decision. Moreover, there is often pressure from patients to do something. When deciding whether and how to treat patients, clinicians consider the following five types of information: • The degree of certainty about the diagnosis, condition, or symptom • What is known about the effectiveness of the various treatment alternatives • What is known about the risks of the treatment alternatives • The clinician's comfort with a particular treatment or intervention • The patient's preference for a certain type of treatment or management In addition, there are resources available with recommendations on when not to provide an intervention because the intervention has no evidence to support that its use would positively impact the condition or outcome (American Board of Internal Medicine Foundation, 2017). The most clear-cut situation is when the condition is definitely present, a particular treatment is known to be highly effective, the treatment can be expected to be low in risk for the particular patient, and the clinician and patient are comfortable with the treatment. Unfortunately, many (probably most) therapeutic decisions are not so clear cut. In these cases, the weight of factors in support of a particular treatment and the weight of those against treatment or in support of another treatment are almost equal. The treatment and management interventions that APRNs perform include a wide variety of self-care modalities and low-tech, nonpharmacologic modalities (Hahn, 2014; Hannon, 2013; MorillaHerrera et al., 2016).When prescribing or recommending medications, APRNs consider the patient's financial status, the patient's previous experience with similar medications, ease of taking the medication, how many other medications the patient is taking, how often the medications must be taken, the side effect profiles of the drugs being considered, and potential drug and disease interactions. A systematic review of nurses as prescribers has shown that APRNs tend to prescribe similar or lower total numbers of medications overall compared with physicians, clinical parameters are the same or better for patients treated by prescribing APRNs, and quality of care is similar or better, with similar or improved patient satisfaction (Van Ruth, Mistiaen, & Francke, 2008). As noted, considerable evidence indicates that APRNs use a broad range of interventions, with substantial reliance on self-care and lowtech interventions. Surveillance, teaching, guidance, counseling, and case management are interventions used more often than procedural interventions (Brooten et al., 2003). The frequency with which the various categories of interventions are used varies moderately with patient populations. The repertoire of interventions used by individual APRNs clearly depends on the problems experienced by the population of patients with whom they work. Acute care NPs, CNMs, CRNAs, and CNSs working in inpatient settings, for example, use repertoires of therapeutic interventions different from those used by APRNs who provide primary care. The interventions that an individual APRN uses also depend on the customs of colleagues, practice setting, and reimbursement system. Nevertheless, APRNs must make an effort to extend and refine their repertoire constantly beyond the interventions learned during graduate education. Individualized Interventions One goal of treatment decision making is to choose from among several possible interventions and to use the one that will have the highest probability of achieving the outcomes the patient most desires. Usually, that probability is increased by particularizing the treatment or action to the individual patient (Benner et al., 1996, p. 24). Particularizing requires that the recommendation or action take the following into account: • Acceptability of the treatment to the patient • What has worked for the patient in the past • Patient's motivation and ability to use or follow the treatment (self-care) • Likelihood that the patient will continue to use the treatment, even if side effects are experienced • Financial burden of the treatment • Health literacy of the patient Nursing has always believed that individualizing nursing care— that is, tailoring care to the unique characteristics of the person and his or her situation—produces the best patient outcomes. In contrast, standardization of care and control of wide variation are important to quality control and cost containment. Clearly, a blending of the two perspectives is required to produce care that is effective for an individual and congruent with available resources. This can be accomplished by adopting evidence-based standards and guidelines to provide a framework for care while acknowledging that at the point of care (i.e., in the patient-provider interface), interventions and management may need to be tailored to reflect the patient's unique situation and needs. Unfortunately, while individualized interventions have been shown to be effective in some cases (Janson, McGrath, Covington, Cheng, & Boushey, 2009; Richards et al., 2007), research support for the effectiveness of individualized interventions in general is not as strong as most APRNs would like. The extent to which the equivocal nature of the evidence is a function of methodologic difficulties in studying individualized interventions is unknown. Part of the difficulty stems from the various ways in which health messages may be customized—personalized, targeted, tailored, and individualized (Ryan & Lauver, 2002). An integrative research review of 20 studies in which interventions with varying degrees of customization to the individual were delivered has revealed that better patient outcomes were achieved with tailored interventions in only 50% of the studies as compared with standard interventions (Ryan & Lauver, 2002). The authors of the review proposed that another reason for the modest support for the efficacy of customized interventions is that patients with certain characteristics are more affected by these interventions than others; such uneven effects across subgroups would offset each other and present an appearance of little or no benefit. Even when a tailored intervention does not result in changed behavior or produce better patient outcomes, it may have other benefits. An example of this collateral gain was found in a study of 43 women with gynecologic cancer (Ward, Donovan, Owen, Grosen, & Serlin, 2000). The individualized sensory and coping message for pain management intervention had no demonstrable effect on analgesic use, pain intensity scores, or pain interference with life, but the women who received the individualized intervention reported that it contained useful information that helped them to feel more comfortable taking pain medication and to discuss pain more openly with a physician or nurse. In today's technology-accessible world, many patients use the Internet to access information and educate themselves about their health and diseases. Patients may actually come to appointments knowing more about their disease than the APRN does. Although this can be disconcerting, it is important to recognize this as informationseeking behavior and capitalize on the opportunity to work with the patients to help them gain the information they need (Cutilli, 2006). Patients vary widely in terms of how much information they want and how they want it presented. Allowing them to make choices about how and what they learn should help prevent content overload and enhance the relevancy of the information given, resulting in better retention and application. Along similar lines, technology can be designed to allow patients to acquire information that is most important to them and to help them sort out their values, priorities, and preferences in their specific situation (Lin & Effken, 2010; Ryan, Pumilia, Henak, & Chang, 2009). It is apparent that technologyassisted learning and decision-making tools will become increasingly more acceptable. It will be important for APRNs to help consumers differentiate among websites that are reputable and offer valid information and those that may not have solid evidence. The Internet is also now used for patients with similar or rare diseases to connect with each other as support in a way that might never have been possible before the advent and ease of use of the Internet. APRNs can also direct patients to state health department websites as excellent sites for accessing helpful information, such as immunization schedules, tobacco cessation tools, and information on diabetes care, sexually transmitted diseases, tuberculosis, and newborn screening. Complementary Therapies The extent of public use of complementary and alternative medicine (CAM) was well documented in the 1990s by Eisenberg and colleagues when they reported that approximately 33% of Americans were using at least one unconventional therapy (Eisenberg, et al., 1993; Eisenberg et al., 1998); this has been further supported in the most recent National Health Survey that included complementary therapy data (Blackwell, Lucas, & Clarke, 2014). Its use in certain ethnic groups is often higher than the national average. Many patients use complementary therapies (i.e., non-mainstream, non-Western therapies) in conjunction with conventional medical services; when complementary therapies are purposefully coordinated with conventional therapies in a treatment plan, the term integrative therapies is used. The effectiveness and safety of complementary and alternative therapies vary widely. Some have been scientifically studied (e.g., relaxation, guided imagery, glucosamine and chondroitin for osteoarthritis), whereas others have not been studied at all. Of concern is that some may interact with other medications that the patient is receiving (National Center for Complementary and Integrative Health, 2016). Another issue specific to dietary supplements and herbal therapy is the lack of control over ingredients (National Center for Complementary and Integrative Health, 2016). Providers are caught between the desire of patients to use alternative therapies and reservations about their safety, often in the face of insufficient scientific evidence. APRNs are incorporating complementary therapies into their practices in a variety of ways, albeit with some caution (Brykczynski, 2012; Maloni, 2013; Steefel, Hyatt & Heider, 2013; Yu, 2014). APRNs have expressed interest in being able to provide CAM for patients, even if it means expanding their scope of practice (Patterson, Kaczorowski, Arthur, Smith, & Mills, 2003). They are increasing their engagement in these therapies, are more willing to ask patients about complementary and alternative therapy practices, and are counseling patients on appropriate use. Many APRNs report a need to increase their own knowledge about complementary and alternative therapies to incorporate it fully into care. An interim solution to this situation may be for an APRN to consider developing a collaborative relationship with an expert CAM provider. In summary, because patients are using these therapies, APRNs seem to believe it is better that they do so with provider guidance and awareness. Clinical Prevention Population-Based Data to Inform Practice The hallmark of the APRN role that differentiates it from other advanced nursing roles is the direct care that the APRN provides in the patient interface. Although this is a key component of the role, it is expected that APRNs also use a clinical prevention and population health focus (AACN, 2006). Clinical prevention refers to the health promotion and risk reduction components of individual health care that are learned as a result of population data. APRNs are considered to be nursing leaders in achieving national health goals for individuals and populations. Interventions outlined in the Healthy People 2020 campaign (Office of Disease Prevention and Health Promotion, 2017) can frequently be instituted or recommended by APRNs, regardless of their roles or settings. Monitoring for current vaccinations, advocating for tobacco cessation with patients, assisting in healthy diets, and identifying opportunities for increasing physical activity are all population-identified behaviors that can be implemented at the individual level. These interventions are key to addressing the increasing disease rates of diabetes, obesity, lung cancer, and asthma. The Healthy People 2020 website (http://www.healthypeople.gov/2020) is a great resource for APRNs and patients to access basic health care information. Work is currently underway to develop national health promotion and disease prevention objectives for Healthy People 2030 (Office of Disease Prevention and Health Promotion, 2017). In addition, APRNs should be cognizant of the ever-changing information related to infectious diseases and emergency preparedness based on today's global health care environment. APRNs can use population trends to inform direct care and improve the assessments and interventions used at the direct care interface. Population data are frequently based on the diseases and conditions prevalent in the geographic setting in which the APRN practices, including the following: • Monitoring for metabolic syndrome in the southeast United States • Assessing for asthma in Virginia • Surveillance for neurological disorders in Minnesota • Cognizance of altitude-based disorders in mountain states • High suspicion for tuberculosis in homeless patients with pulmonary symptoms who live in densely populated urban settings Aggregated, individual clinical outcomes are also useful for the evaluation of program and practice effectiveness. By requiring that care be administered and individual outcomes be documented in standardized ways, the health care system can conduct programmatic evaluations of clinical outcomes. Population-based evaluations can also be used by APRNs to evaluate and improve the care they provide. Such evaluations can help answer questions such as the following: • “Is the specific care I (we) provide patients the best way of managing their health or illness?” • “Are my (our) patients doing as well as similar patients who are cared for by other providers?” Conducting such an evaluation involves the following: (1) identifying groups of patients (i.e., populations) who have high costs of care, less than optimal outcomes, or both; (2) monitoring and analyzing variances in outcomes and costs; (3) examining processes of care to determine how management of the condition could be improved; and (4) incorporating management methods found to be effective in research or best practice networks. For example, population data in New Mexico have revealed a high mortality rate from alcoholism, prompting the state to invest more in alcoholism prevention programs and emphasize a sharper clinical focus on substance abuse. Evaluation of the degree to which desirable outcomes are attained enables health care systems to compare their effectiveness with that of a comparable system or to evaluate the relative effectiveness of a new program or process of care. These types of evaluations and comparisons can lead to the identification of best practice methods at the health care system level. Use of services, readmission rates, complication rates, average total cost per case, and mortality rates are examples of population outcomes used in various types of evaluations and comparisons. Preventive Services in Primary Care Health promotion and disease prevention interventions are tools that APRNs in primary care regularly use to help people achieve and maintain a high quality of life. These preventive services include the following: • Counseling regarding personal health practices that can protect a person from disease or promote screening for the presence of disease • Immunization to prevent specific diseases • Chemoprevention (e.g., use of aspirin for prevention of cardiovascular events) Discernment is needed in the use of these interventions because time and effort can be wasted if their use is not based on current scientific knowledge and tailored to the individual person or community. Also, the public is confused regarding many of the preventive recommendations because new research evidence has been unseating long-established recommendations, such as the value of breast self-examination. The US Preventive Services Task Force (https://www.uspreventiveservicestaskforce.org) and the Canadian Task Force on Preventive Health Care (http://canadiantaskforce.ca) provide specific preventive guidelines for many health conditions. These include valuable summaries of the state of the science for each recommendation. An important point made in the early document “Guide to Clinical Preventive Services” (US Preventive Services Task Force, 1996) is that primary prevention in the form of counseling aimed at changing health-related behavior may be more effective than diagnostic screening and testing. Many healthy people, as well as those who have had a recent health scare, are receptive to—even eager for— information and guidance about how to stay healthy and avoid agerelated disabilities. However, other people who engage in one or several unhealthy behaviors can be defensive and resistant to talking about their risks and how behavior changes could reduce risks. Introducing behavior change issues with unreceptive people requires a high level of interpersonal skill and a good sense of timing. An APRN must consider that it is possible that no health care provider has previously attempted to discuss the problem (e.g., smoking, lack of exercise, alcohol abuse) with the person, even though signs of a problem have existed for a long time. Talking about the risks of the current behavior and benefits of the behavior change is not enough. To be effective, counseling regarding these issues should also include a discussion of how the person perceives the burden of changing a personal behavior—that is, what would be lost and what would be required to make the change? The provider must first make the patient feel understood and must elicit how much effort will be required, what would give the individual the confidence to change, and which forms of self-help assistance are acceptable to the individual. Then and only then can a specific recommendation about a strategy or program be made. Theoretical models that can be useful in planning a behavior change program or protocol include the Transtheoretical Model (Cancer Prevention Research Center, University of Rhode Island, 2017) and the Health Belief Model (Resource Center for Adolescent Pregnancy Prevention, 2017). Both models include provider strategies for building a person's self-efficacy—confidence in one's ability to take action. Clinicians also have at their disposal a wide array of screening tools, some of which are better with certain populations or age groups than others. For example, the US Preventive Services Task Force (2012) currently recommends against routinely screening women older than age 65 for cervical cancer if they have had an adequate recent screening with normal Papanicolaou (Pap) test results and are not otherwise at risk; they also recommend against performing routine Pap tests for women who have had a total hysterectomy as treatment for benign disease. Staying current with the latest screening recommendations in one's area of practice ensures that care is provided in a way that is scientific and cost-effective. Preventive Services in Hospitals and Home Care The preventive services provided in inpatient and home care settings are somewhat different from those provided in primary care. Many of the actions and assessments performed on behalf of acutely ill patients are aimed at early detection and prevention of problems related to treatment, disease progression, self-care deficits, or the hospital environment itself. Complications typically result from a complex set of factors, such as inadequate delivery systems or failure to assess patients for risk of complications common to their condition. Nurses assist patients by preventing adverse events and complications, including adverse medication reactions, unexpected physiologic decline, poor communication, pressure ulcers, and death. As noted earlier, this function is also termed surveillance or rescuing (as in rescuing from a bad course of events or death). In the home setting, APRNs serve as advisors and partners. In addition to assessment and surveillance, guidance and coaching are particularly important. The patient may be new to the role of partner in this setting (Holman & Lorig, 2004). APRNs work with patients to prioritize measures that might prevent rehospitalizations. Interventions may include teaching about reportable signs and symptoms, guidance on how to communicate with their providers, and assistance in making connections between behaviors and situations in the home that directly affect health status. Management of Complex Situations APRNs' direct care often involves the management and coordination of complex situations. Many illustrations of this advanced practice nursing feature may be found in the chapters on specific advanced practice nursing roles (see Chapters 14 through 18). In some settings, APRNs have been designated as the providers responsible for coordination of complex follow-up care (Bradway et al., 2012; Looman et al., 2013; Morilla-Herrera et al., 2016). APRNs manage diverse and complex patient conditions and care requirements, which include the following: • Confusion in older hospitalized patients and acute care of the elderly (ACE) units • Frail older adults • Pain in patients who are chronically or terminally ill • Acute pain • High-risk pregnant women • Long-term mechanical ventilation • Heart failure patients • Neurosurgical patients • Pediatric and adult palliative care • Critically ill neonates Many APRNs have been called in for consultation when there is a need for skilled communication, advocacy, or coordination of the various providers' plans—or some combination thereof (Exemplar 7.4). The patient's condition may not be improving because wound care, pain management, and physical therapy have not been well thought out and coordinated. Family members may be angry because plans keep changing and they are receiving conflicting information from various providers. Typically, the APRN talks with the patient and family to become familiar with their concerns and objectives and then brokers a new plan of care that reflects the patient's and family's needs and preferences, as well as the clinical objectives of the involved providers. The agreed-on plan must also be consistent with the care authorized by the third-party payers for the patient, or a special agreement must be negotiated. This brokering requires broad clinical knowledge regarding the objectives of various providers, interpersonal skill in dealing with the results of misunderstandings, diplomacy to encourage stakeholders to see each other's points of view, and a commitment to keeping the patient's needs at the center of what is being done. Exemplar 7.4 Management of Complex Patient Situationsa C.M. is a diabetes clinical nurse specialist with 20 years of experience. She works in an 800-bed academic medical center, where she is accountable for overall outcomes of glycemic control in the inpatient setting. She is also responsible for evaluating, treating, and educating patients with complex diabetes needs. C.M. has been asked to consult on and write treatment recommendations for a 30-year-old Somali woman. Before seeing the patient, C.M. reviewed the chart to ascertain patient history and information. The patient was diagnosed with type 2 diabetes mellitus (DM) 11 years ago and had been on oral hypoglycemic agents, although not well controlled. She has been managed by multiple providers over the years. The patient was not married and had two sons, 13 and 17 years of age; both have been diagnosed with type 1 DM. Documentation in the chart indicated that the patient had been admitted to the hospital in diabetic ketoacidosis (DKA) caused by presumed nonadherence to her regimen. The health care team had initiated an insulin infusion but had not initiated the DKA protocol and had been having difficulty getting the patient's glucose level in the target range. When C.M. entered the patient's room, she saw an African woman with truncal obesity, a puffy face, acne, and facial hair. The patient did not make eye contact and appeared standoffish. The patient was reluctant to answer questions. C.M. recognized the need to proceed thoughtfully in developing a relationship with the patient to establish trust. C.M. also realized that multiple visits would be required to fully ascertain the extent of needs for this complex patient. From C.M.'s experience and knowledge base, she knew that the symptomatology of DM in the African population is different from the typical presentation of DM in Caucasians. Type 1 DM symptoms in the African population may not be as severe on initial presentation and may not reflect ketosis; therefore this population can be misdiagnosed with type 2 DM and started on oral agents when they actually have type 1 DM and should be treated with insulin. C.M. suspected that this might have been the case with this patient. In addition, on first glance, C.M. immediately suspected that the patient had other endocrine issues (e.g., adrenal dysfunction or polycystic ovary syndrome) because of the presence of puffy face, acne, and facial hair. C.M. decided the priority for this initial visit was to focus on the physical care aspects while clarifying the diagnosis and prescribing appropriate treatment to control the patient's glucose. She performed a physical examination and ordered the following diagnostic tests: • C-peptide and antibodies (to differentiate between types 1 and 2 DM) • Fasting cortisol • Adrenocorticotropic hormone stimulation test • Estradiol-androgen panel • 24-hour urine • Endocrinologist consult • Initiation of standardized DKA protocol C.M. returned the following day with the intent to explore knowledge and psychosocial areas with the patient. Again, the patient was wary in her interaction but started to have better eye contact. C.M. started by asking about the patient's psychosocial situation and determined that the patient was making ends meet financially. However, there were income issues, and C.M. determined that a social work referral was in order. The patient described having a good relationship with her sons and acknowledged an extensive family support system in the community. She identified herself as a Christian, not a Muslim, as most people assumed. C.M. then started to inquire about the physical signs she had noticed on the previous visit by asking how long the patient had had acne and facial hair. At that point, the patient started to cry and stated that C.M. was the first person to have ever asked her about it. They were clearly distressing symptoms for the patient, and she relayed that she had tried multiple over-the-counter products to try to resolve the acne, but without success. C.M. shared with the patient what she suspected might be happening with other endocrine issues and reassured her that if that were the case, prescription dermatology creams and hormone therapies would help resolve the symptoms. It was at this point that the patient realized that C.M. was committed to helping her and a therapeutic relationship began to develop. The patient was now more receptive to allowing a full knowledge assessment. C.M. discovered that the patient understood DM well and knew how to count carbohydrates and how to use that information when planning meals. Although the patient spoke English well, C.M. discovered that the patient could not read English and had some visual disturbances. What had been labeled as nonadherence was actually an inability to read and see health care instructions. When C.M. reviewed the diagnostic test results, it was determined that the patient had Cushing's syndrome, polycystic ovary syndrome, and type 1 DM, rather than type 2. Over the following days, in educational sessions with C.M., the patient quickly gained knowledge about insulin and how to administer it, and she became proficient at using a magnifier to read the insulin syringe. C.M. developed instructional tools that did not require the ability to read complicated English. Whenever the patient's sons were present, they were included in the teaching. The patient was eventually discharged to home with new knowledge of insulin and type 1 DM management, as well as information about her new diagnoses and medications, ongoing support from external social services, and referral to a physician group that could manage the health needs of the entire family and provide continuity of care over time. Highlights of Advanced Practice Nursing Care of a Complex Patient This case exemplifies the role that an APRN can play in making accurate diagnoses and optimizing care for a complex patient. C.M. exhibited the following: • Use of evidence and knowledge of unique population-based data applied to an individual patient, which resulted in prompt correction of a diabetes misdiagnosis • Expert clinical assessment and intervention skills that identified new endocrine diagnoses and assisted in rapid correction of glycemic control • Holistic approach to care, incorporating cultural assessment, psychosocial needs, and barriers to knowledge • Individualized interventions to meet patient needs • Interpersonal approach that allowed for rapid development of a trusting therapeutic relationship with a patient who was traditionally wary of health care providers who had consistently misidentified her as noncompliant a The author gratefully acknowledges Carol Manchester, MSN, APRN, CNS, BC-ADM, CDE, for the use of her exemplar. Helping Patients Manage Chronic Illnesses Another type of complex situation that APRNs manage effectively is chronic illness. Chronic diseases such as multiple sclerosis, cognitive degeneration, psoriasis, heart failure, chronic lung disease, cancer, acquired immunodeficiency syndrome (AIDS), and organ failure with subsequent transplantation affect individuals and families in profound ways. Most chronic illnesses are characterized by a great deal of uncertainty—uncertainty about the future life course, effectiveness of treatment, chances of leading a happy life, bodily functions, medical bills, and intimate relationships (Mast, 1995). The unique perceptions that the patient can experience with uncertainty in chronic illness has led to the proposal of a new model integrating the two concepts: the Health Change Trajectory Model (Christensen, 2015). For a variety of reasons related to the characteristics of advanced practice nursing, APRNs are successful in providing care in this complex situation to persons with chronic conditions and their families. The US Department of Health and Human Services (HHS) has issued proposed rules for health care providers and systems based on the Patient Protection and Affordable Care Act (2010) to improve the coordination of patient care, particularly those with chronic or complex illnesses, through the establishment of accountable care organizations (HHS, 2011). Although the details of any specific legislative efforts will certainly change with time, the essential foundation of this accountable care organizations effort is to place patients at the center of their care, maintain quality standards of care, and lower health care costs. APRNs who see chronically ill patients in a primary care or specialty setting improve care by coordinating the services patients receive from multiple providers. Chronic illnesses often affect several body systems or have numerous sequelae. Thus persons who are chronically ill often receive care from a primary care provider and several other clinicians, including physicians and APRN specialists, social workers, physical therapists, and dietitians. Without coordination, families coping with chronic illness can find themselves in an “agency maze” (Burton, 1995, p. 457). This vivid phrase captures the confusing experiences that ensue when the agencies and providers rendering care to a family do not communicate with one another. Families do not know where to go for help and, as a result, many resort to a trial-and-error approach to getting what they need. They often suffer the negative effects of misinformation, repetitive intake interviews, denial of service, conflicting approaches, and unsolved problems. A resource-savvy APRN can often assess these situations and intervene to reduce stress, improve communication, and benefit patients and families. By contacting other providers to develop a coordinated management plan and by linking patients with suitable agencies, the APRN can do much to relieve the burdens of chronic illness on a family. Among the reasons that APRNs are successful in providing care to persons with chronic illness is their advocacy of patient self-care. It has been proposed that the key to self-care by patients with chronic illness is to provide self-management education and support in conjunction with traditional patient education (McGowan, 2012). Selfmanagement education is aimed at promoting confidence to carry out new behaviors, teaching the identification and solving of problems, and setting patient-directed, short-term goals (Lorig, Ritter, & Gonzalez, 2003; McGowan, 2012). Many self-management educational interventions for those with chronic conditions are designed to bolster patients' sense of self-efficacy related to coping with their condition and gaining control over the impact of the disease on their lives. This can include engaging patients in shared decision making, promoting healthy lifestyles, and monitoring of symptoms (McGowan, 2012), all of which APRNs are skilled at providing and supporting. Although self-management education has had mixed results to date in physical and psychological health improvements, it is believed that it is a useful component of a comprehensive, chronic disease management program (Brady et al., 2013; McGowan, 2012). Partnership in the management of a chronic illness requires a change in roles for patients and providers. Patients develop daily management skills, changes in behaviors, and accurate reporting of symptoms. Although providers continue as advisers and partners, they now also become teachers, a role that many are not adequately prepared to fulfill (Holman & Lorig, 2004). In this new partnership, patients develop more knowledge and experience over time and they know the most about the real consequences of chronic disease and their behaviors. There are barriers to using a self-management education program in today's health care environment. These include lack of trained personnel in this intervention, patient dependence on the medical model that has been facilitated by paternalistic health care providers, and lack of reimbursement for these services (Bodenheimer & Grumbach, 2007). Regardless, results of this model are compelling, with need for further research because the aging of the US population will only result in increasing numbers of patients living with chronic illness. Through the use of diverse approaches and individualized, interpersonal, and therapeutic interventions, APRNs have the skills and resources to partner in managing populations throughout the care continuum, from preventive care to the most complex care required by patients with a chronic condition. This is important in view of the increasing complexity of patients' health problems in today's society. Direct Care and Information Management Health care is an information-rich environment. It has been said that health care encounters occur essentially for the exchange of information—between the patient and care provider and among care providers themselves (Committee on Quality Health Care in America, IOM, 2001). With the adoption of information technology (IT), health care information management has become increasingly complex. Inadequate resources and difficulty in accessing information at the time it is needed complicate the situation further (Committee on Quality Health Care in America, IOM, 2001). The IOM report recommended that government, health care leaders, and vendors work collaboratively to build an information infrastructure quickly to eliminate handwritten clinical data by the end of 2010. With the implementation of the Affordable Care Act, the HHS has made recommendations to encourage widespread implementation of electronic systems and databases to facilitate access to seamless and accessible health care information for everyone (HHS, 2010). Although there is still much to do, it is believed that appropriate use of these systems will decrease errors in prescribing and dosing, increase appropriate use of best practice guidelines, reduce redundancy, improve access to information for patients and providers, and improve quality of care. The direct care practice of APRNs is directly influenced by these changes as increasing numbers of health care systems and clinics implement electronic health records and databases. The DNP Essentials task force recognized the increasing importance of information systems for APRN practice and education. Essential IV of the DNP Essentials requires that APRNs be prepared to participate in design, selection, and evaluation of systems used for outcomes and quality improvement; exhibit leadership in the area of legal and ethical issues related to information systems; and be knowledgeable about how to evaluate consumer sources of information available through technology (AACN, 2006). Borycki, Cummings, Kushniruk, and Saranto (2017) have outlined additional nursing informatics competencies required of multiple levels of nurses. With rapid changes in technology, it will be an ongoing challenge throughout an APRN's career to remain current in this area. There is an expectation of increasing competence in the use of technology that can be a challenge for some APRNs. Wilbright et al. (2006) surveyed 454 nursing staff at all role levels in their self-reported skill in 11 key areas of computer use. Although the APRNs reported excellent to good skills at entering orders and accessing laboratory results, they rated their skills as fair or poor in 5 of 11 areas that were deemed essential to their role. APRNs may still struggle with optimal use of MEDLINE or CINAHL or skills such as use of Excel spreadsheets and project management programs, which may be essential to optimal functioning in their roles. If APRNs struggle with the need for increasingly complex technology skills, it will be difficult for them to use tools and their time optimally to care for their patients. Well-functioning information systems can ease the workload of the APRN by optimizing the management of extensive data. However, meaningful IT needs more development to overcome challenges that APRNs may face on a daily basis in their use of IT, such as workflow disruptions, lack of interfaces between systems, work-arounds, in which providers subvert the IT to get the job done, and inappropriate use of order entry warning alerts (Magrabi, Ong, Runciman, & Coiera, 2010, 2012; Palojoki, Mäkelä, Lehtonen, & Saranto, 2016). Computer technology may actually require increased staff time when used for complex order entry and clinical documentation. Health care institutions and private practices are rapidly implementing information systems across the country, so it is likely that APRNs will work in an environment in which a system is being implemented or upgraded. APRNs can have an impact on how these systems function to make them user-friendly and efficient at the direct care interface. Although APRNs may feel they have neither the time, inclination, nor expertise to participate in these implementations, user input is imperative and ultimately affects direct care. As information systems are implemented, APRNs need to be cognizant of the potential for at least a temporary increase in errors, reduced charge capture, incomplete or difficult-to-access information, and increased time for routine tasks. Implementation of these systems is a major undertaking because it takes time to re-equilibrate workflow and organizational skills, regardless of APRN experience. When information systems are well implemented and used, the APRN will be able to use and view data in new ways to improve patient care. The expansion of technology can lead to a corresponding increase in the number of tools and amount of data that are available for use— both within and external to the health care setting. Examples include: email or video communication with patients rather than telephone calls or office visits, patient use of “apps” to assist with dietary selections and recording intake when eating at restaurants, patient use of personal fitness devices that record activity levels and calories expended, data that can be downloaded and transmitted from mobile invasive technology to maintain life, the practice of telehealth for routine or specialty patient care, and the use of computers to assist in oncology protocol care decisions (e.g., Watson for Oncology: https://www.ibm.com/watson/health/oncology-andgenomics/oncology/). One commonality throughout these examples is the need to determine when and how to use these data to make patient care decisions (Harrington, 2017). There will be a need for robust analytics to obtain meaning from these data, and APRNs must partner with informaticists and be at the table when determining strategy regarding when and how to use analytics (Harrington, 2016a). The goal is to integrate technology with practice for valueadded benefit (Harrington, 2016b). Although information systems and electronic resources can be great tools in the APRN's repertoire, the APRN must be constantly aware that these technologies bring with them their own pitfalls and unique potential for errors (Harrington, 2014). APRNs can play important roles in evaluating proposed technology and information management systems and the impact they have on APRN practice and patient care. Conclusion The central competency of advanced practice nursing is direct care, regardless of the specific role of the CNS, NP, CRNA, or CNM. APRNs are currently providing direct health care services that affect patients' health care outcomes positively and that are qualitatively different from those provided by other health care professionals. Of importance, these services are valued by the public and are costeffective. APRNs can offer this essential care through the use of the six characteristics that comprise APRN direct care: use of a holistic perspective, formation of therapeutic partnerships with patients, expert clinical performance, use of reflective practice, use of evidence as a guide to practice, and use of diverse approaches to health and illness management. Their mastery accomplishes several goals, including differentiation of practice at an advanced level and context for the development of other competencies, such as consultation and collaboration. Together, these characteristics form a solid foundation for providing scientifically based, person-centered, and outcomevalidated health care. Research evidence supports each of these claims and hence substantiates the nursing profession's and public's confidence in the care provided by APRNs. As APRNs continue to expand the scope and settings of their practice, it will be imperative that these six characteristics continue to be substantiated by solid research in each of the roles. In addition, research will be important in documenting the optimal so-called nurse dose of APRN intervention as we continue to face challenges in caring for culturally diverse, aging, and chronically ill populations. Key Summary Points ▪ Direct care is the central APRN competency. ▪ The six characteristics of direct care are: use of a holistic perspective, formation of therapeutic partnerships with patients, expert clinical performance, use of reflective practice, use of evidence as a guide to practice, and use of diverse approaches to health and illness management. ▪ While APRNs provide many strategic functions throughout and over the course of their role, time needs to continue to be spent in direct clinical care with patients in order to maintain differentiation between the APRN role and other DNP-prepared non-APRN roles. ▪ Mastery of these six characteristics of direct care delineates the differentiation of practice at an advanced level and sets the foundation for attaining skill in the other APRN competencies. References Agency for Healthcare Research and Quality. Health literacy: Hidden barriers and practical strategies. 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Johnson “You don't have to see the first staircase, just take the first step.” —Martin Luther King, Jr. CHAPTER CONTENTS Why Guidance and Coaching?, 180 Patient Engagement, 180 Burden of Chronic Illness, 180 Context of Guidance and Coaching: Definition and Skills, 181 Guidance, 181 Coaching, 182 Theories and Research Supporting APRN Guidance and Coaching, 183 Nightingale's Environmental Theory, 183 Midrange Theory of Integrative Nurse Coaching, 184 Transtheoretical Model, 185 Watson's Model of Caring, 186 Positive Psychology, 186 Growth Mindset, 187 Self-Determination Theory, 187 Transitions in Health and Illness, 187 APRN Guidance and Coaching Skills, 189 Listen, 189 Build Strengths, 190 Cultivate Unconditional Positive Regard, 191 Cultivate a Culture of Empathy, 193 Create a Safe Environment, 193 Self-Knowledge as an APRN, 194 APRN Proficiencies Specific to Coaching, 196 Ask Permission, 196 Support Small Changes, 196 Be Curious, 197 Getting to the Feelings, 197 APRN Coaching Process, 197 Patient Readiness, 197 Preparation, 199 Action, 199 Maintenance, 199 The “Four As” of the Coaching Process, 199 Agenda Setting, 200 Awareness Raising, 200 Actions and Goal Setting, 200 Accountability, 201 The Dilemma of Guiding or Leading From Behind, 201 Building Coaching Into Practice, 202 Conclusion, 202 Key Summary Points, 202 This chapter defines guidance and coaching as distinct advanced practice registered nurse (APRN) competencies that are at the heart of nursing and are an effective means to engage patients in change leading to healthier lives. Since researchers first identified the teaching-coaching function of expert nurses and APRNs, guidance and coaching by APRNs have been researched, integrated into APRN competencies, and described through case studies and other writings about APRN practice (Benner, 1984; Benner, Hooper-Kyriakidis, & Stannard, 1999; Fenton & Brykczynski, 1993). The American Association of Colleges of Nursing Essentials (Master's and doctoral knowledge, skills and competencies) have guidance and coaching integrated into nearly every competency, be it leadership, role development, or health promotion (American Association of Colleges of Nursing, 1996, 2006). Engaging others effectively to build rapport through deep listening is a key competency for all APRNs to build an authentic therapeutic exchange with patients. The core competencies of APRN guidance and coaching are explicated here within the context of theory and research. In addition, a description of which APRN situations are appropriate for guiding patients and which are appropriate for coaching patients is emphasized. Foundational skills of the coaching methodology are discussed, and guidance and coaching skills will be contrasted. Integrative health care, often linked with guidance and coaching, is not fully covered in this chapter; rather, a thorough discussion explores the relational skills needed across all four APRN roles. (See Chapter 7 for a discussion of integrative therapies in APRN practice.) Why Guidance and Coaching? Patient Engagement In the United States, and around the world, people with serious illnesses or chronic conditions account for a disproportionate share of national health care spending. One of the main drivers of the Affordable Care Act (ACA) was to lower costs and reduce persistent racial disparities (Patient Protection and Affordable Care Act, 2010). Research shows that a multipronged approach is needed to reduce costs and health disparities and includes redesigning primary care, developing care teams that are accountable across sites of care, and managing transitions and medications (Schoen et al., 2011). Health providers working together with patients have the opportunity to design personalized interventions to sustain patients' involvement in their treatment and encourage patients to take an active role in their own health and health care. Guiding and coaching patients requires activation and empowerment through placing the responsibility of the pursuit of health where it rightly belongs—with the patient. The ACA provided the structure to activate and empower patients by giving patients critical information about quality, enhancing patient-centered care through client-centered medical homes, and financing new models of care that empower patients. These elements of the ACA are designed to engage patients in their treatment, developing their abilities to manage their health and lower their modifiable risks, helping them express concerns and preferences regarding treatment, empowering them to ask questions about treatment options, and building strategic patient-provider partnerships through shared decision making (Chen, Mullins, Novak, & Thomas, 2016). Recognizing patients as the source of control for their health requires building confidence and empowerment and not having health care providers simply tell patients what they need to do. This shift to a more patient-centered approach is a major component of improvement of population health. Burden of Chronic Illness The current biomedical model of care does not work for lifestylerelated diseases. Chronic diseases—including heart disease, stroke, type 2 diabetes, cancer, and chronic lung diseases—account for most deaths in the United States and globally and are costly, debilitating, and preventable (Centers for Disease Control and Prevention [CDC], 2016b). The World Health Organization (WHO) has identified four major risk factors responsible for the worldwide disease burden that now eclipses communicable diseases: (1) tobacco use, (2) poor diet, (3) alcohol abuse, and (4) physical inactivity. These four behaviors are responsible for 4 of every 5 deaths in the world and represent the most significant modifiable risk factors causing the chronic illness epidemic worldwide (WHO, 2014). Helping patients change these behaviors will greatly decrease untold suffering, early mortality, and disability. A startling statistic that represents opportunity for behavior change is that there are now more overweight people than undernourished people throughout the world (IFRC, 2011). This chronic illness epidemic is an impending disaster for worldwide health, for society, and for the global macroeconomy. Chronic noncommunicable diseases create a debilitating blow to economic development. They cause billions of dollars in losses of national income and push millions of people below the poverty line, each and every year (IFRC, 2011). In the United States alone, chronic diseases attributable to lifestyle factors are responsible for 7 of 10 deaths each year, and they account for 86% of our nation's health care costs, which in 2013 were $2.9 trillion (CDC, 2016b). As every APRN knows, lifestyles associated with chronic illness can be prevented by choosing healthy behaviors. People can reduce their chances of getting a chronic disease or improve their health and quality of life if they already have a chronic disease by making healthy choices. The CDC (2016a) found that only 6.3% of US adults engaged in all five key health behaviors that can reduce their risk of chronic diseases: (1) avoiding alcohol consumption or only drinking in moderation; (2) exercising regularly; (3) getting enough sleep: (4) maintaining a healthy body weight; and (5) not smoking. These findings, based on nearly 400,000 adults aged 21 and older, showed that 1% failed to engage in any of the five health behaviors, while 24% engaged in four, 35% engaged in three, and 24% engaged in two. As APRNs bring a sharp focus to lifestyle change that can be addressed through guidance and coaching, their value in the health care marketplace will be more fully realized. Context of Guidance and Coaching: Definition and Skills There are relational approaches that focus on helping a person create change in his or her life to advance individual autonomy, well-being, and goal attainment. Although there is overlap among the approaches, several aspects differentiate them, such as length of time of engagement and the focus of the interaction. Understanding the characteristics of guidance versus coaching is a key APRN competency that is built on having trust and rapport with patients. Guidance Guidance is a broad term that means the provision of help, instruction, or assistance, and there are several forms of guidance. The distinguishing feature of guidance as compared to coaching is that guidance requires the provision of advice or education, whereas coaching is an inquiry, an excavation of answers from a person. To guide is to advise, or show the way to others, so guidance can be considered the act of providing expert counsel by leading, directing, or advising. To guide also means to assist a person to travel through or reach a destination in an unfamiliar area. Guidance is best used in situations when a person has a perceived knowledge deficit in an area for which expert APRN knowledge can fill the void. When providing guidance, the APRN is serving as a knowledge source for the patient. Guidance can include laying out, simplifying, or integrating the options for a patient to make a health care decision. It is imperative that the APRN determine the patient's level of knowledge before launching into guidance. Asking patients what they know about their condition is an important skill to respectfully build on what they know and make APRN guidance more powerful and effective. What follows are some common forms of guidance. Anticipatory Guidance Anticipatory guidance and teaching is a particular type of guidance aimed at helping patients and families know what to expect. Anticipating common problems or symptoms and what to do about them can go a long way in reducing unnecessary care and promoting self-efficacy, as well as in reducing a patient's anxiety. Anticipatory guidance is when the APRN informs the patient a priori about an expected health process that is likely to occur. For example when a patient sustains a cervical hyperextension injury (whiplash) after a car accident and a fracture has been ruled out, the APRN informs the patient that the muscles surrounding the neck will become far more painful within 48 hours. She or he may explain that torticollis may ensue and that this is normal, temporary, and to be expected. The APRN offers remedies and guidelines on when to seek more assessment. Another example of anticipatory guidance is when a woman experiences a miscarriage and the APRN lets the patient know to expect very heavy blood loss that may alarm her. The APRN provides guidelines about when to seek additional care, offers reassurance, and anticipates that the patient may experience intense feelings of loss and grief. Patient Education Patient empowerment can be achieved by teaching patients about their illnesses/conditions and by guiding them to be more involved in decisions related to ongoing care and treatment. The WHO defines patient education more broadly as any combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes (WHO, 2016). The goal of patient education is to produce change and self-care. Clinicians have long thought that if the patient is provided with the right information, the patient will see the wisdom of making change in his or her life to be healthier and simply follow the recommendations. For APRNs it is essential to determine what a person wants to learn before launching into a teaching or “telling” expert role. Patients often come with an array of information from available websites and other sources. As information has become so readily available, patients are looking for customized wisdom and a broker of information to cut through the large amount of confusing, often conflicting, sources of knowledge. They want to know what information applies to them and how should they use it. (See Chapter 7 for further discussion of patient education.) Mentoring There are many definitions of mentoring, but essentially it is a one-onone relational process in which one person having more expertise or experience in a particular area provides guidance to another person. Mentors and mentees often have long-term relationships, sometimes for an entire career or lifetime. Although mentors help mentees move toward their goals, the goals of mentees are usually consistent with the career goals of the mentors. The similarity in interests is usually based on a shared knowledge area or achievement of a position. Mentors provide advice and support based on their experience to help their mentees attain their goals. The mentoring relationship can be highly structured, with set times for meetings and agendas, or very informal, with meetings at intervals as the mentee desires. These relationships are beneficial to both parties because the participants offer each other different perspectives and framing on modern APRN problems. The mentor is exposed to fresh thinking and to APRN problems that the mentee many be facing. Mentees are offered a longer view, wisdom, and perspective. Counseling In 20/20: A Vision for the Future of Counseling: The New Consensus Definition of Counseling, the American Counseling Association defines counseling as the following: Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. (Kaplan, Tarvydas, & Gladding, 2014, p. 368) Counseling can be a very long-term relationship that is focused on helping individuals address their problems. Counseling can take place within a work setting through programs such as employee assistance or with individuals on a personal basis. Counseling is generally focused on psychological, social, or performance issues. The key distinction is that counseling is intended to “fix” a problem through gaining insight and advice from the counselor. Counseling as a technique operates from a problem-based approach as opposed to building on a person's strengths. Coaching Coaching is a broad umbrella term that encompasses different approaches, philosophies, techniques, and disciplines. Coaching is defined by the International Coach Federation (ICF) as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential” (ICF, 2016a). For APRNs this definition also extends to a health potential. The ICF (2016a) identified four main components of a coach's responsibility: • Discover, clarify, and align with what the client wants to achieve • Encourage client self-discovery • Elicit client-generated solutions and strategies • Hold the client responsible and accountable The ICF definition and components of coaching provide significant leeway in the development of different philosophical approaches to coaching. Although there are common principles, there are different philosophies and schools of thought in the coaching sphere. One example is motivational coaching, based on a focused approach to explore and ignite motivation for change and address ambivalence. Another is integrative coaching, developed by Duke University to help patients make changes to lead healthier lives (Duke Integrative Health, 2016). Integrative coaching is intended to address the gap between medical recommendations and the patient's success in implementing the recommendations. Each of these approaches has commonalities, including working toward change that is defined by a patient. In addition, there are different foci of coaching, such as health and wellness, executive, life transition, end of life, and attentiondeficit/hyperactivity coaching, to name a few. A meta-analysis on coaching by Sonesh et al. (2015) found wide-ranging impacts of coaching, including that coaching is an effective way to change patient behaviors and improve leadership skills, job performance, and skill development. Specific findings included that coaching: • Improves personal and work attitudes, including selfefficacy, commitment to the organization, and reducing stress. • Can elicit a strong bond, which in turn facilitates joint goal setting, and may be the mechanism through which goals are reached. Coaching is based on a relationship in which the individual identifies his or her goals. It is founded on the recognition that the person seeking coaching is mentally healthy and has internal resources to deploy toward attaining her or his goals. The role of the coach is to work with that person in accomplishing those goals. The coach helps individuals clarify, define, reflect, and move forward. Coaching can be thought of as leading change from behind as well as walking with the patient (McLean, 2012). This concept clearly puts the individual in charge while the coach fully engages with the patient. Coaching can last from a “spot” coaching session of one time to several years in length. Many coaching relationships last about 6 to 10 interactions to move a person forward far enough so that he or she can self-coach to continue to attain and sustain her goals. There is considerable discussion within coaching as to how much advice giving should be offered. Because coaching is usually considered a partnership with an individual requiring the asking of powerful questions, the APRN must trust that the person has her or his own answers that are true and right for him or her. However, working with patients to make change is different in that providers have specific health-related information that patients need and want. Providing that information is providing guidance within a coaching context. Combining coaching with guidance is essential to a complete provider-patient relationship. Table 8.1 differentiates guidance and coaching. TABLE 8.1 Elements of Guidance and Coaching Competencies Guidance Coaching Expert APRN has higher authority gradient Power is shared APRN is the expert Patient is the expert/has the answers Provides advice Seeks understanding Fixes problems Builds on strengths Expertise is valued Curiosity is valued Telling Asking Teaching Inquiring Anticipates Explores APRN leads/sets agenda Patient leads/sets agenda Nurse Coaching Nurse coaching is aimed at working with individuals to promote their maximal health potential by integrating the skills of nursing and coaching. The relatively new International Nurse Coach Association supports the concept of integrative nurse coaching. Hess and colleagues (2012) have created momentum to integrate coaching into all registered nurse programs. Professional nurse coaching is defined as “a skilled, purposeful, results-oriented, and structured relationshipcentered interaction with clients provided by a registered nurse for the purpose of promoting achievement of client goals” (Dossey, Luck, Schaub, 2015, p. 3). Although this definition is specific to nursing and nursing care, it is consistent with the intent of the ICF definition. The International Nurse Coach Association offers certification as a nurse coach through their text The Art and Science of Nursing Coaching: The Providers Guide to the Nursing Scope and Competencies (Dossey et al., 2013), published by the American Nurses Association (ANA), as well as Nurse Coaching: Integrative Approaches for Health and Wellbeing (Dossey, Luck, & Schaub, 2015). These works have been endorsed by the American Holistic Nurses Association. Coaching has been explicitly integrated into several APRN practices, although the extent is unknown. Hayes and Kalmakis (2007) have asserted that coaching is a critical component of a holistic care approach for nurse practitioners. Most midwives might say that their practice incorporates coaching throughout the mother's pregnancy and delivery (Exemplar 8.1). There has long been the concept of being a labor coach within midwifery. Clinical nurse specialists have worked within the spheres of both consultant and coach. As coaches, they have worked with patients and family members to manage multiple chronic illnesses or a specific disease. Many clinical nurse specialists have roles that incorporate coaching when working with nurses to develop skills. A certified registered nurse anesthetist uses coaching to customize and personalize pain management or anesthesia to meet the patient's stated goals and needs. Exemplar 8.1 Being a Midwife and Family Nurse Practitioner Is Being a Coach Dawn Lovelace DNP, CNM, FNP Dawn Lovelace, DNP, RN, CNM, FNP, is both a certified nursemidwife (CNM) of 22 years and a family nurse practitioner (FNP) of 17 years who believes coaching is integral to her practice. She lives in Grand Coulee, Washington, an area with approximately 1000 people in the town and about 10,000 people in the 20-square-mile service area surrounding the town. She and several colleagues worked to build a full-scope health service with her focus on developing maternity care services that did not exist. She was on call 24/7 for births, saw patients 4 days a week in clinic, and provided emergency room coverage. She saw patients in the hospital and nursing home. The practice has added more clinicians and is now a medical home. Dr. Lovelace says that coaching has always been part of “being” a midwife and FNP, and she has a strong commitment to helping people be as healthy as possible. As a midwife, she helps a woman prepare for and meet her goals for the birth as well as helping her become a parent. The beauty of coaching pregnant women is that she has 9 months and often much longer to engage in a coaching relationship. Coaching has been part of the very deep and long value she has had. It is integral to her personal belief system. She starts where the person is, helps her evolve based on her reproductive life plan, and determines how to help get her there. For Dr. Lovelace, it is difficult to tease out what is coaching because it is so embedded within the role. She describes how being with women outside the hospital setting helps one truly be present with them. She knows she is present when she loses track of time and is in the “zone” or “flow.” She has used the transformative power of pregnancy and birth knowing that this is a time of life when people want to grow and that tapping into that desire is easy. When asked what she likes best about coaching, Dr. Lovelace says she has seen so many amazing outcomes of coaching. She described working with a 14-year-old pregnant girl who was heavily involved in drugs. Dr. Lovelace's coaching went beyond the birthing process as she worked with the young woman to get her life together. In spite of every roadblock conceivable, that young woman is now in college and is an effective parent. She also described another young girl who came for birth control and who was going from house to house sleeping on sofas. This young woman is now a nurse practitioner, and when she recently saw Dr. Lovelace, she said that it was really important in how she saw herself that Dr. Lovelace treated her like a human being and saw the potential in her. When asked what she would say to her students about integrating coaching into their practice, Dr. Lovelace quickly said, “Start where the person is. Accept them where they are. We all have people we don't like, but we need to accept them and don't ever write anyone off.” In asking how she would advise students to be able to be present with patients, Dr. Lovelace said, “It takes work and self-evaluation, you need to know your prejudices and beliefs. We have off days in which we don't listen but we need to keep working at deep listening. Helping people figure out how to change their lives—that is what matters. You have to be committed to having coaching being part of your practice and value it.” Theories and Research Supporting APRN Guidance and Coaching There are numerous evidence-based theories and frameworks that inform the APRN guidance and coaching competency. These are deeply rooted in Florence Nightingale's environmental theory as well as the science of human caring, which broadens and deepens the therapeutic use of self. In fact, the importance of the APRN-patient therapeutic relationship is foundational to the APRN guidance and coaching competency. Although there are many theories and models, we will note those that are important to informing and developing the APRN guidance and coaching competency. Nightingale's Environmental Theory Florence Nightingale's Notes on Nursing: What It Is and What It Is Not (1860), makes a strong link between a person's environment and her or his health. Working with a person to manage his or her environment is the fundamental role of nursing, and as we experience a chronic illness epidemic in modern times, this observation still holds true. In fact, Nightingale built the foundation of nursing as a distinct profession on her observation that external factors associated with patients' surroundings greatly affect their lives, their development, and their biologic and physiologic processes (Nightingale, 1860). This seminal conceptual thinking lies at the heart of modern APRN guidance and coaching. Midrange Theory of Integrative Nurse Coaching A theoretical framework for nurse coaching has been developed by Dossey and colleagues (2015). They defined an integrative nurse coaching framework as “a distinct nursing role that places clients/patients at the center and assists them in establishing health goals, creating change in lifestyle behaviors for health promotion and disease management, and implementing integrative modalities as appropriate” (p. 29). The authors identified five components of this model: (1) self-reflection, self-assessment, self-evaluation, and selfcare; (2) integral perspectives and change; (3) integrative lifestyle health and well-being; (4) awareness and choice; and (5) listening with HEART (healing, energy, awareness, resiliency, and transformation) (Dossey et al., 2015, p. 29). Based on this theoretical framework, the ANA published a guide to nurse coaching competencies (Dossey et al., 2013) (Exemplar 8.2). Exemplar 8.2 The Story of a Nurse Coach Champion Barbara Dossey PhD, RN, AHN-BC, FAAN, HWNC-BC Barbara Dossey is changing the practice of nursing. She has been building on 50+ years of nursing experience, including a 23-year focus in critical care and cardiovascular nursing. As she cared for critically ill patients, she realized that many of her patients could have prevented their serious health issues if they had changed their lifestyles. That was the beginning of her focus on holistic nursing, healing rituals, and health and wellness through coaching. In 2010 a seminal experience for Dr. Dossey occurred after an interprofessional coaching conference with over 1000 people, where not a single nurse presented on a topic that is the foundation of nursing. She asked herself, “Where are the nurses in this health and wellness coaching conversation, what can I do, and how can I do it?” Her answer was to look at the power of coaching as an integral role and part of nursing practice. Dr. Dossey then moved quickly—knowing how to create change. She invited five like-minded holistic nursing colleagues engaged in health and wellness coaching to craft a roadmap to move the philosophy and role of coaching into mainstream nursing. Strategically, she and her colleagues obtained permission to use the American Nurses Association template of nursing specialties scope and standards and developed a template for coaching applicable to all levels and disciplines within nursing. As a result, she and her colleagues published The Art and Science of Nurse Coaching: A Provider's Guide to Scope and Competencies (Dossey et al., 2013). This is the study guide for the American Holistic Nurses Credentialing Corporation Nurse Coach certification examination. She and two colleagues also developed the Theory of Integrative Nurse Coaching, a midrange theoretical model for nurse coaching, and published the first Nurse Coach textbook, Nurse Coaching: Integrative Approaches for Health and Wellbeing (Dossey, Luck, & Schaub, 2015). Dr. Dossey speaks eloquently about the “heart” of nursing being coaching. As she considers advanced practice registered nurse (APRN) work, she describes APRN clinical expertise as necessary but not sufficient and says that coaching brings the “heart” of nursing back to the APRN-patient relationship. It is the integration that fulfills Florence Nightingale's vision of nursing as focused on the health of humanity and a healthy world—local to global. Her philosophy is firmly based on the richness of the integrative nurse coaching model. She is clear that the requisite to being an effective nurse coach is to know yourself and to continuously develop oneself through self-awareness, self-reflection, selfevaluation, and self-care. As we go to a deeper level of our own story, we can listen at a deeper level to patient stories to more effectively help them to create healthy change—often with baby steps leading to sustained change and healing on many levels. Dr. Dossey speaks passionately about the beauty of hearing the stories of patients and how important that is to understanding who each patient is and what patients' hopes are for their health in order to help them understand their own strengths and resilience. She believes that APRNs have deep capacity to bear witness—to let go of their agenda and to be aware of the qualities of stillness and be open to the present moment. The critical component of an APRN working effectively with a patient is to work with the patient to identify his or her goals, strengths, and actions for change, and to be present and listen with HEART (healing, energy, awareness, resilience, and transformation). Dr. Dossey believes that positive psychology is key to coaching by believing in the strengths that patients have and recognizing that everybody has resilience. When APRNs increase the self-awareness of patients, those patients make better choices and have power to make life changes. She knows this can be done because she has a personal nurse practitioner care provider who has integrated coaching into her practice and begins each visit with a joyful greeting of “I am very glad to see you and I want to hear what you have being doing since I last saw you,” setting the stage for deep listening and hearing Dr. Dossey's story. The focus is on her as a patient and a person, not on a routine physical examination or a symptom. Transtheoretical Model The transtheoretical model is an integration of several hundred psychotherapy and behavior change theories, hence the term trans (Prochaska, Redding, & Evers, 2002). Using smokers as research subjects, Prochaska et al. learned that behavior change unfolds through a series of sequenced stages of change, which were not delineated in any of the existing multitude of theories. The transtheoretical model has been used successfully in a number of maladaptive lifestyle behaviors such as alcohol and substance abuse, eating disorders, anxiety/panic disorders, obesity, sedentary lifestyles, high-risk sexual behavior, and nonadherent medication use. This model is highly relevant to the APRN who can tailor the intervention to the patient's specific stage of change to maximize the likelihood that the patient will proceed through a needed change process. Providing specific knowledge about disease trajectories or prevention strategies and advice is overused and often counterproductive when it comes to motivating patients toward sustained lifestyle change. A thorough discussion on readiness for change and application of this theory is provided later in this chapter. Watson's Model of Caring The theoretical framework for Watson's model of caring is based on loving kindness. Her work has focused on the science of caring and moving from carative to caratas (love), that is, the process of relating to others in an authentically present way, going beyond the ego (Watson, 2017). The APRN would go beyond self-interest and ego to fully and spiritually integrate body, mind, and spirit. This model provides a strong feelings-based approach to coaching, recognizing the openness of spirit to another person as essential in a therapeutic relationship. Honoring and respecting the patient's values, history, beliefs, autonomy, goals, and being is foundational in this model. It also requires self-reflection for the APRN to reach deep love and respect in a relationship. This includes, for example, being present to and supportive of the expression of positive and negative feelings, the creative use of self and using all ways of knowing, and assisting with basic needs with intentional caring consciousness (Watson, 2017). Positive Psychology Seligman (2011) found five dimensions that lead to a flourishing life or a high degree of well-being (Fig. 8.1). These dimensions can be cultivated to build one's capacity to flourish. The five dimensions of positive psychology are directly applicable to the APRN interacting with a wide range of people. In looking at the dimension of positive emotions as an example, Fredrickson (2001) proposed that feeling positive emotions broadens people's momentary thought-action choices, which builds their enduring personal resources. Broadening and building suggest that the capacity to experience positive emotions may be a fundamental human strength central to human well-being. The APRN can facilitate a person's positive psychology, especially in a guidance and coaching interaction, by promoting any or all of the five dimensions of well-being. FIG 8.1 The theory of well-being. (From Seligman, M. E. P. [2011]. Flourish: A visionary new understanding of happiness and well-being. New York, NY: Free Press.) Growth Mindset Dweck (2006), in her study of mindset and its impact on achievement, found that there are two types of belief systems. One is a growth mindset in which the individual believes she or he can learn and practice and achieve success. In addition, there is the belief that hard effort can remedy setbacks and that people with a growth mindset have a high degree of resilience. Fixed mindset people believe they are endowed with talents that are fixed; they focus on documenting and defending their talent rather than developing skills. People with fixed mindsets de-link talent from effort, acting on the belief that talent is a fixed, immutable entity. Fostering a growth mindset in the clinical space can create motivation and productivity, leading to improved outcomes. Guiding patients to shift from a hunger for approval (fixed mindset) to a passion for learning (growth mindset) by the tiniest degree can have profound impact on nearly every aspect of life (Dweck, 2006). Self-Determination Theory Ryan and Deci (2006) provide a framework for the understanding of human motivation and conditions that promote it and thwart it. The theory purports that there are two forms of motivation, intrinsic and extrinsic, and that all humans are motivated both by rewards (outside of ourselves) and by our interests, curiosity, and abiding values (inside). This framework offers three conditions that are associated with the level of a person's motivation for engagement (Fig. 8.2). These three psychological needs have a robust impact on wellness (Ryan & Deci, 2006). FIG 8.2 Self-determination theory posits that all humans have three central areas of motivation: competence, autonomy, and relatedness. This framework is directly applicable to the APRN guidance and coaching competency because the APRN can promote the environment that supports competence, autonomy, and human relatedness (Exemplar 8.3). When these three needs are satisfied, it leads to enhanced self-motivation and health, and when thwarted, diminishes motivation and well-being. Placing high value on positive regard, warmth, and giving patients as much psychological freedom as possible will lead to more engaged patients and better health outcomes (Ryan & Deci, 2000). Exemplar 8.3 My Journey From the ICU to Wellness Eva Schmidt APRN, FNP-BC, CHWC Starting my nursing career as an ICU nurse, I witnessed first-hand the unnecessary devastation of poor lifestyle choices and very often poorly informed choices. Almost from the very beginning, I found myself questioning how such patients had ended up there. Who had failed them? What could have been different for them? I started asking questions and quickly learned that it wasn't about a lack of desire to change. Most of the patients had tried. Many had even been through disease education programs. So, what was missing? My deep desire to answer that question is, in part, what led me to become a nurse practitioner. I knew I needed to act “upstream,” before an illness appeared, and that maybe I could help more people from that vantage point. I also knew that the foundation of the nurse practitioner role is based on health promotion and disease prevention. I intended to build on that concept to help people improve their health, not just treat disease and illness. When I finished my NP program, I went to work for a 10physician family practice. I had high hopes and stars in my eyes about how I would practice. They, however, had a different idea. I was seeing nearly 30 patients a day, never getting to really know any of them. I always felt as if I had my hand on the door, watching the clock, knowing the next patient had already been waiting too long. I was not only exhausted, I was sad. It became clear to me how those ICU patients had been failed. I finally had to ask myself, “Now what?” I took a leap of faith and partnered with a physician in that practice to start our own MD-NP practice. Being the owner of my own practice seemed to be the answer. It was going to provide a new opportunity for me to finally deliver care in the way I knew it should be. We offered 30-minute appointments and were committed to delivering a different experience. At least I was. Word got out! We were very successful. Within 5 years we had built a practice of over 5000 patients. Having a business background, it made perfect sense for me to act as the practice administrator as well as a full-time provider. However, it didn't take long to see the signs. We were slowly falling into the same trap. I found myself working 24/7 just to keep up. I had no time for the very thing I set out to accomplish—putting the patients first! As that environment became more toxic, with my partner and I having more and more disagreements about how I would practice, I began ignoring my own health. By the end of the fifth year, I had gained 40 pounds and was in the worst shape of my life. I started to feel like an imposter. I was supposed to be helping people improve their health and I certainly wasn't “walking the talk.” I was spending so much time trying to prove myself as an equal to my physician partner that I had lost sight of the very foundation I started out on. I was failing my own patients and knew the only way to gain integrity with them was to gain integrity with myself and my own health. It was time to let the physician do his work and to focus on applying my NP skills where it would be most impactful. I had one particular patient at that time who I had been seeing for several months. She was 150 pounds overweight, with all of the comorbidities one would expect. She was on several medications, and it seemed that despite her apparent desire to lose weight, each visit was spent adjusting those medications as the number on the scale continued to climb. I would give her a list of “good foods” and “bad foods.” I'd advise her on how to cook, how to shop, and how to exercise. Yet every visit she would sit in my exam room and cry, saying things like “I don't know why I can't seem to stay on a diet” or “I was so bad this week.” I knew we needed a new approach. I finally started asking her why losing the weight was important to her. She admitted that she didn't want to follow in her mother's footsteps; her mother had a heart attack before the age of 55 and died at 60. Once I took off the expert hat and we started focusing on her own motivation for change, the weight started coming off. She was able to set small goals for herself at each visit that led to lasting behavior changes. Within 6 months, she had lost over 70 pounds and is now off all of her medications. I started using that approach with more patients. I would use the time scheduled for “follow up” or “medication checks” to have powerful conversations about wellness. I saw more improvements in the next 12 months than I had in 5 years with some of them. It became clear to me that coaching patients by putting them in the driver's seat was leading to much better outcomes. It felt right, stepping back and empowering the patients to make decisions about why, what, and how they would change. I was also building warmth and trust with them, making the visits very positive for both of us. As my work life improved, so did my own health. I made the decision to leave that practice and toxic business partner. It has reinforced for me that health coaching, combined with foundational nursing concepts, is what our society needs. I know that through the coaching competency, I'm impacting people's lives and blazing a trail to better health outcomes. It has also established that when I'm taking care of myself, I'm a stronger advocate and role model for my patients. Transitions in Health and Illness The emerging importance of guidance and coaching is also related to a better understanding of the importance of assisting patients with a variety of life experiences in order to reduce health care costs and increase quality of care (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). Early work by Schumacher and Meleis (1994) remains relevant to the APRN guidance and coaching competency and contemporary interventions, often delivered by APRNs, designed to ensure smooth transitions for patients as they move across settings (e.g., Aging and Disability Resource Centers, 2011; Coleman & Berenson, 2004; Coleman & Boult, 2003). Schumacher and Meleis (1994) defined the term transition as a passage from one life phase, condition, or status to another: “Transition refers to both the process and outcome of complex personenvironment interactions. It may involve more than one person and is embedded in the context and the situation” (Chick & Meleis, 1986, pp. 239-240). Transitions have been characterized according to type, conditions, and universal properties. Schumacher and Meleis (1994) have proposed four types of transitions—developmental, health and illness, situational, and organizational. Developmental transitions are those that reflect life cycle transitions, such as adolescence, parenthood, and aging. Health and illness transitions require not only adapting to an illness but more broadly reducing risk factors to prevent illness, changing unhealthy lifestyle behaviors, and numerous other clinical phenomena. Situational transitions are most likely to include changes in educational, work, and family roles. These can also result from changes in intangible or tangible structures or resources (e.g., loss of a relationship or financial reversals) (Schumacher & Meleis, 1994). Organizational transitions are those that occur in the environment: within agencies, between agencies, or in society. They reflect changes in structures and resources at a system level. Developmental, health and illness, and situational transitions are the most likely to lead to clinical encounters requiring guidance and coaching. Successful outcomes of guidance and coaching related to transitions include subjective well-being, role mastery, and well-being of relationships, all components of quality of life (Schumacher & Meleis, 1994). This description of transitions as a focus for APRNs underscores the need for and the importance of incorporating guidance and coaching into the APRN-patient therapeutic partnerships. APRN Guidance and Coaching Skills There are several important skills that must be in place to establish effective relationships. Chapter 7 presents a thorough discussion on communication with patients and with those who are unable to fully participate in verbal communication. These skills are necessary to be an effective APRN. Even though the skills noted in this section are part of basic nursing care, the following discussion of skills is described within the context of APRN guidance and coaching. Note that there is considerable interaction among the skills—they are interdependent and should be part of every APRN toolbox. Listen We listen every day. It is part of our ability as human beings (as long as our hearing is anatomically and physiologically intact). However, how often are we thinking of other things when someone is talking to us? We intend to give our attention to the patients we serve—but there is so much work to do and so many patients to see. Every aspect of patient care has to do with highly skilled listening: listening for energy, what the person wants or needs, resistance, choices made, and how choices move toward or away from goals. Coaching in particular requires that patients do most of the talking, with the APRN doing most of the listening. We could not adequately guide patients or do anticipatory teaching without knowing what the person already understands. Rachel Naomi Remen (2006) is a pioneer of relationship-centered care and has noted, “The most basic and powerful way to connect with another person is to listen. Just listen. Perhaps the most important thing we give to each other is our attention” (p. 34). Listening is a foundational skill to both guidance and coaching and in any relationship. Listening is the process of understanding others and establishing trust in the relationship. Trust is the foundation of the APRN–patient therapeutic relationship. There are several different taxonomies of listening. A useful classification described by Whitworth and colleagues (2007) includes three levels of listening (Fig. 8.3). The level 1 listener is tuned out, either ignoring the person talking or pretending to listen. This level is also referred to as internal listening, where the listening is all about the listener. Level 2 listening is selective, with the listener sometimes focusing but at times being distracted by his own inner dialogue. Level 2 listening has a sharper focus on the other person than level 1. In level 3, the APRN becomes a mirror in which the information is reflected back. This listening is collaborative, empathic, and clarifying. The APRN is unattached to his agenda and his own interests. Level 3 is empathic listening, representing the highest level, in which the listener gives time and attention to listening and gives her or his full self. Empathic listening is not only hearing what is said but also understanding the words, emotion, and meaning. It is considered “deep” listening or listening with the heart. Deep listening is hearing what is not said and includes tone of voice and nonverbal expressions. It is a global form of listening, in which one is using all the senses to listen, noticing gestures, the action, inaction, and interaction. It requires the APRN to be very open and softly focused without an agenda or judgment of any kind. Level 3 listening is often described as a force field with invisible radio waves in which only the skilled listener can receive the information, often unobservable to the untrained listener (Whitworth et al., 2007). Guiding and coaching require Level 3 listening in order to fully engage with the patient's baseline knowledge, goals, actions, and emotions. Suggestions for level 2 and 3 listening are: FIG 8.3 Levels of listening. • Stop talking! • Relax for a minute prior to engaging with a patient by deep breathing, visualizing a pleasant memory that triggers relaxation. • Review the health record prior to beginning a dialogue. • Remove distractions and potential interruptions, and clear your head of intruding thoughts. • Listen for the tone of the conversation as well as the words. • Acknowledge what is said by reflecting and probing further. • Ask powerful questions. Literature reflecting the benefits of listening includes patient satisfaction with care, enhanced patient engagement in care planning, and improved health outcomes (Wentlandt et al., 2016). Listening is the most critical of skills for APRNs, as discussed in Chapter 7. There is no guidance or coaching without deep listening. Build Strengths There is an increasing recognition that building on patient strengths is a way for patients to gain confidence in their ability to change. The tendency in the past has been to focus on what is broken, not working, or what an individual does not do well. This is likely based on the medical model paradigm, that the health issues that a patient has are the result of not doing something or not doing something correctly, and that gap needs to be addressed. Rather than fixing what is broken, building on strengths can make the broken parts desiccate and shrink. For example, if a person has a great appreciation for excellence in their profession, that inherent skill can be applied to a weight loss journey by raising the quality of food they are ingesting or using love of learning to experiment with different strategies to manage their stress. A recent interprofessional summit was convened to identify that a major change that must occur in care delivery is to build on patient strengths to assist patients to achieve their goals (Swartwout, Drenkard, McGuinn, Grant, & El-Zein, 2016). The recent focus on building strengths is based on seminal research by Peterson and Seligman (2004), who demonstrated the benefit of assessing and using people's strengths in making and sustaining change in a person's life. There are years of research showing the benefits of building on strengths (Values in Action [VIA] Institute on Character, 2016). The Classification of Strengths is an important tool that has been used in a growing body of evidence since the mid-1990s (Peterson & Park, 2009). This classification has six “virtues”—wisdom and knowledge, courage, humanity, justice, temperance, and transcendence. In addition, there are 24 characteristics within the overall classification (Table 8.2). Although the research has not been specific to health care, there are clearly applications to health promotion by assessing and then building on patients' strengths for a healthier future. TABLE 8.2 From Peterson, C., & Seligman, M. (2004). Character strengths and virtues: A handbook and classification. Washington, DC: APA Press/Oxford, England: Oxford University Press. Building on strengths has become an approach broadly used in health coaching (Exemplar 8.4). Confidence gained from building on strengths helps individuals to not only deploy those strengths toward achieving their goals but to also work on areas to be developed. Often people do not recognize their strengths, and the initial work of the APRN is to help the patient identify her strengths. There are strengths assessments available online that have strong validity profiles. One example is the VIA Survey of Character Strengths, which can be found at http://www.viacharacter.org/www/Character-Strengths-Survey. If there is no formal VIA assessment, the APRN can help the patient recognize his or her strengths to build on by asking: Exemplar 8.4 Patient Seeking Coaching for Obesity, Prediabetes, and Migraine Pain Deborah McElligott DNP, HWNC-BC Setting: Nurse practitioner (NP) private coaching practice. Issue: Marie's Narrative: Marie is a 35-year-old female who comes to the office to see what a “coaching session” entails. She has a history of migraines, obesity, prediabetes, and fatigue. She is married, works full time, and has two children under the age of 7. Her migraine pain ranges from 5 to 8 (scale of 1 to 10), with nausea and occasional vomiting; the symptoms are worse with stress and relieved by her “additional migraine medication” and lying down, but followed by a day of fatigue and dull 2- to 4-level pain. The frequency ranges from three times a week to once a month, with no identifiable pattern. Marie has seen multiple specialists over the last 20 years, including her primary care physician, neurologist, pain specialist, allergist, and chiropractor. Her laboratory values are normal with the exception of an elevated hemoglobin A1c (5.7%). Her body mass index was 30 and her body fat was 42%. Session 1 Marie scheduled a 1-hour appointment with the NP for a coaching session after reading an article linking lifestyle to migraines. The NP prepared for the appointment by reviewing the questionnaires Marie completed online and then doing a brief centering exercise before Marie entered the room. During the introductions, the NP described the coaching process and asked Marie what she was hoping for (eliciting the agenda). She described her need to lose weight in order to have the energy to care for her family and complete her responsibilities at work. She was fearful of “diabetes” because she has a family history (personal motivators). Although she has had migraines for 15 years, her increased responsibilities have made coping with them more difficult (awareness raised about the link to stress). The NP reflected that Marie did have a lot on her plate. Marie was clearly ready to make changes but didn't know where to begin (moving from contemplation to preparation). The NP asked if she could share what others in her situation have done and Marie was interested. The NP shared that some patients have found a relationship between food, stress, and headaches, receiving some relief by following an elimination food plan. Marie said she tried everything—she had been to an allergist, nutritionist, Weight Watchers. She did lose some weight, but her headaches didn't improve (resistance emerging). The NP recognized the success Marie had in the past and focused on her strengths. Marie acknowledged that she did feel lighter and had more energy with the weight loss. But her most recent attempt at Weight Watchers failed and her migraines didn't decrease. She was willing to try anything. The NP asked if she could review the elimination food plan (a chart of healthy foods to eat while eliminating dairy and gluten) and a food log planner (chart to log food, activity, migraine, sleep, bowel movement, and stress) with her and Marie agreed. The NP identified that the purpose for the tracking was for Marie to be able to identify any patterns that existed. Marie said she had done all these things in the past but not together. She said she would do this, she was ready to try and would “complete the log sheet each day and eat only the foods on the chart for 2 weeks.” The NP asked how confident she was that she could do this (on a scale of 1 to 10) and Marie replied 5. She felt it was easy enough but that stress either at work or at home may trigger her to eat the wrong food. The NP asked what would make it a 7. Marie replied that if she could control her stress, she would be more confident in her plan. On questioning, Marie preferred to run to reduce stress, but identified that running is not an option at work or when caring for the kids, so she eats. The NP asked if Marie wanted to try a short meditation and she agreed. After a 5-minute practice, Marie replied that she felt relaxed and was confident that she could incorporate this into her plan—she said she almost felt like she had had a nap. At the end of the session, Marie agreed to log her food, eliminate dairy and gluten (for 1 week), and do 5 minutes of meditation 4 days a week (actions/goal setting). She was going to be accountable to the NP and come back in 1 week to review the plan and see if patterns emerged. Her new confidence level rose to a 7 of 10. Sessions 2–7 Marie returned for weekly visits. On week 2 she had only one migraine, improved sleep, and success with her meditation—she logged everything on her weekly log sheet and noted an extremely busy day prior to her migraine. Over the next 3 weeks she continued on the elimination plan as her energy increased and her cravings for sugar decreased. The NP explored her next goals and Marie wanted to decrease her migraine medications. The NP asked her to speak to her neurologist before she made any medication changes. Marie also wanted to begin an exercise plan—she already belonged to a gym, and set a goal to exercise 3 times a week for 30 minutes prior to going to work. The NP asked if she would begin to reintroduce dairy or gluten but Marie did not want to. She continued on the elimination plan with an occasional “cheat day.” Session 8 By week 8 Marie had been successful in meeting her activity goal, food goal, meditation, and food log. She decreased her migraine medication to half the dose, had an average of two migraines a month, and didn't need any additional medication to control them. She felt better, her clothes were looser, and people noticed a difference in her appearance, even though she had only lost 1 pound. She became aware that she was building muscle. The NP summarized all the changes she had made as they compared her initial evaluations to the most recent one, seeing a dramatic decrease in symptoms. Her A1c was 5.6%. She was less stressed and had more energy. She was determined to stay on her routine and was comfortable introducing small amounts of gluten on special occasions. Marie continues to follow up with her medical team, feeling empowered by her efforts. • “Tell me about a challenge that you feel you successfully managed.” • “What would your friends and family say were the best parts about you?” • “What strengths helped you be successful?” • “How would you describe your strengths to create the change you want to make?” APRNs can incorporate strength finding into any visit. Identifying strengths could take place during the history or physical examination. APRNs already respect, value, and engage with each patient, and identifying and building on their strengths will help in the APRN efforts to build capacity to relate well to patients. Cultivate Unconditional Positive Regard At times we may be frustrated with a patient because she or he does not follow advice or adhere to a care plan. There are patients whose political philosophy may be different, who may be racist, who like to smoke, and who are highly resistant to change. There may be patients who are difficult to relate to. Having unconditional positive regard (UPR) for all people does not mean we have to like every patient. Mearns (1994) noted that liking someone is based on shared values and complimentary needs and is therefore conditional. However, it is especially important to have UPR for all patients and particularly for those we find most frustrating. UPR is essential to building a trusting and effective relationship. Being completely accepting toward another person, without reservations (UPR), is a concept developed by the psychologist Carl Rogers. He proposed that each individual has vast resources to marshal for self-understanding and self-directed behavior but an interpersonal climate of positive regard was necessary to facilitate this (Rogers, 1961). Joseph (2012) defined UPR as “valuing the person as doing their best to move forward in their lives constructively and respecting the person's right to self-determination no matter what they choose to do” (p. 1 on website). It is about accepting a person as he or she is and without judgment. It has been the basis for patientcentered therapy. It is important to note that UPR also includes setting boundaries by creating clarity of expectations in the relationship. Examples of boundaries linked to UPR include not supporting hurtful behaviors or being treated disrespectfully as an APRN. Each APRN needs to establish her or his own set of boundaries and clarify and maintain them with her or his patients. Cultivate a Culture of Empathy Carl Rogers built on Maslow's hierarchy of needs by adding that in order for a person to “grow,” she or he needs acceptance, genuineness, and empathy. Rogers believed that each person can achieve his or her deepest desires in life and achieve self-actualization, but that empathy helps foster that growth, just the way that a seed needs soil and water. His greatest contribution was in his study of accurate empathy and its role in the growth of humans. He described empathy as an underappreciated way of being and posited that accurate empathy is “being one with the patient in the here and now, being highly sensitive to their experience and their world” (p. 34). He stressed that listening is not a passive endeavor because active listening can bring about changes in people's attitudes toward themselves. People who experience accurate empathy and are listened to in this way become more emotionally mature, more open, and less defensive (Rogers, 1961). There is increasing recognition and evidence that provider–patient relationships, the quality of their communications, and accurate empathy influence quality, safety, and health outcomes (Price, Elliott, Zaslavsky, et al., 2014). The upcoming section in this chapter on “Self-Knowledge as an APRN” focuses on the skills essential to cultivating a culture of empathy. Create a Safe Environment Creating a safe environment includes deep listening, unconditional positive regard, and other elements of presence. A patient must feel physically and psychologically safe in order to fully engage in a relationship. We often take for granted that people seek health care and trust APRNs to do the best for them simply because we are credentialed health care providers. However, they often feel that they must “please us” rather than be honest about their concerns. Pleasing a provider is deeply rooted in patient behavior. Patients want their APRN to like them. They may be afraid that the APRN will be angry or judgmental of them if they are challenging or have not adhered to a treatment plan, so they may tell APRNs what they think we want to hear. Patients' desire to please is ultimately derived from a fear that if the provider does not like them, they will not get good care. There are reasons for patients wanting APRNs to like them based on a vast literature related to prejudice and bias. Currently, more attention is being paid to implicit (unconscious) bias as a contributing factor in health disparities in the United States. One definition of implicit bias is “attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner” (Kirwan Institute, 2015). Everyone has implicit biases. Kahneman (2011) included a summary of research that has taken place on bias in his book Thinking Fast and Slow. Biases are not only based on race, ethnicity, or religion but may be based on manner of dress, weight, gender, political views, and other issues. And they may be based on how we perceive the behavior of a patient as a patient. Is the patient deferential? Is he or she personable? Is she or he a complainer? We often give subtle messages of greater acceptance when patients are “compliant” and of nonacceptance if they are not. That message can be conveyed simply through a smile or frown. APRNs in a coaching mode need to invite open conversation and let patients know that it is safe for them to challenge and to be honest about their issues. Creating the safe environment will support having a truthful conversation with the APRN far above any kind of approval-seeking by the patient. In addition to establishing safety within a relationship, there are considerations about establishing safety in the environment. A room with “thin walls” that is sterile and unpleasant may inhibit a patient from feeling safe. Creating an inviting and accepting environment can be a challenge but one that is worth the time. Having pictures on the wall, freshly painted rooms with privacy, and places to comfortably sit are critical to establishing an environment of safety. Some health care services have to manage the potential of physical violence in creating safe places. Accomplishing this in any clinical space will require engaging many different people in order to invest in creating a safe physical environment. Paying attention to the environment tells patients that you care about them. The space in which we engage patients needs to match the eloquence of the conversations we are having with them on a daily basis. Self-Knowledge as an APRN An important element of integrating guidance and coaching into APRN clinical practice is knowing yourself as a person (see Chapter 7). This differentiates coaching from mentoring, consulting and advising, and motivational interviewing. Although we want to form relationships with our patients that lead to highly important, impactful, and meaningful outcomes, each of us has a unique understanding of others and of ourselves. Being an effective APRN requires staying open and teachable to new learning and selfreflection to continue to grow. Learning not only includes staying current with emerging health care evidence but, perhaps most importantly, knowing ourselves and growing personally and professionally. McLean (2012) has formulated a model of self that applies to the APRN. She identifies six areas of self-knowledge that are useful in optimizing the role as coach: presence, empathetic stance, boundary awareness, somatic awareness, range of feelings, and courage to challenge. Presence How well honed is your ability to be present? Thich Nhat Hah (2015), a Buddhist philosopher, has said, “The most precious gift we can give others is our presence.” In a guiding or coaching relationship, presence is not only a gift but a prerequisite to being a full partner. The International Coach Federation defines coaching presence as the “ability to be fully conscious and create [a] spontaneous relationship with the client, employing a style that is open, flexible and confident” (ICF, 2016b). This definition uses the word “fully conscious”; others may use the words “fully aware” or “mindful.” Some people equate the words “mindful” and “presence.” A definition of mindfulness is noted by Bazarko (2013), a nurse working in the area of mindfulness. She writes, “Mindfulness means to purposefully pay attention in the present moment with a sense of acceptance and nonjudgment” (p. 109). The commonality of both definitions is paying attention and being fully conscious. Presence requires mindfulness and mindfulness requires presence. Being present is foundational to building a trusting relationship with the patient (see Chapter 7). McLean (2012) points out that a useful way to think about presence and coaching is being alert to “what's being said, what's not being said, what's being acted out, what's observable somatically and what's a pattern you have observed before” (p. 26). In other words, being present means coming to the relationship with listening at levels 2 and 3 as described earlier in the “Listen” section. There are two common pitfalls to being present that relate to APRNs: external distractions and the well-honed ability to try and anticipate what the patient needs. We are often physically present, but our minds tend to jump from one thought to another. When you are with a patient, you may be thinking about the patient you just saw, your frustration with one of your colleagues, or getting your child to basketball practice. When you take the time to be aware of what you think during a patient visit, you may be astounded by how many thoughts unrelated to the patient enter your mind. In addition to the challenges of our work environment, we have deeply rooted ways of thinking as APRNs to anticipate patient problems. (See Chapter 7 for a discussion on thinking errors in practice.) We have been taught that we need to have answers for problems so we can fix a problem and thereby fix a patient. We think ahead of what we hear from the patient. Once we start anticipating, we have stopped being present. We need to slow our thinking and follow what the patient is saying. This is a fundamental challenge to the APRN coach. The art of nurse coaching is to develop the ability to set aside distractions—including jumping ahead in problem solving, which often leads to misdiagnosis and care that is not patient centered —and engage fully in the moment with the patient. Presence can be enhanced through practice, which can take place at any time. It may be useful to start the day with 5 minutes of doing nothing or to spend 1 minute doing nothing before seeing each patient. Practice being aware of when you are not present and bring yourself back to being present. When you find you are not present, do not consider that a failure, just bring yourself back to being present. Practice at home and at work. The more you practice being present, the easier it will be to achieve. Both you and your patients will benefit. Empathic Stance To what extent are you able to be empathic? Empathy has been described as being able to walk in another person's shoes and is foundational to nursing and coaching. It is the ability to understand and share the feelings of another. This requires knowing the boundaries of your empathy, which can range from one extreme of accepting a patient's emotions as your emotions to the other extreme of failing to recognize a patient's emotional status altogether. Although empathy is woven into basic nursing, as we get pressed for time and get frustrated by demands of patients, exhibiting empathy requires constant vigilance. Although we accept empathy as an emotional state, there is increasing understanding of the neurophysiology of empathy. Research beginning in the mid-1990s has led to identifying neural networks of “mirror neurons” that may explain the capacity for empathy (Rizzolatti & Craighero, 2004). Mirror neurons are activated by both the action of an individual and the observation of a similar action performed by another (Lamm & Majdandzic, 2015; Preston & de Waal, 2002). It appears that mirror neural pathways extend to multiple structures in the brain based on the stimuli producing the effect. A possible explanation for empathy is that when we are listening to and looking at a patient, our mirror neurons are activated as if we are experiencing what the patient is doing or experiencing. With ongoing research into mirror neurons, there is great promise to better understand the neural activation that forms and supports relationships and how feelings are experienced. One way of expanding empathy is to record a visit with a patient and reflect on the content of the visit. Ask yourself if you were listening and able to reflect back to the patient your understanding of the feelings the patient was experiencing. Were you able to walk in that patient's shoes? The more experiences that we personally have in a variety of situations, particularly with illness and encounters with the health care system, enables us to better understand patient experiences. Boundary Awareness Do you know your boundaries with your patients? The concept of boundary awareness in coaching is founded on the initial work of Kerr and Bowen (1988) on self-differentiation within the context of family. The concept of self-differentiation can be extended to any unit of people and is explained by Kerr and Bowen (1988), who state, “The more differentiated a self, the more a person can be an individual while in emotional contact with the group” (p. 235). The important concept in Bowen's theory is centered on differentiation with the extreme of emotional fusion in which a coach would become part of the patient's system, experiencing the patient's feelings and needs. In an APRN coaching relationship, there is a fine line between boundaries that are too tight and those that are too loose, and it can be a significant challenge to maintain a coaching balance. To be more aware of boundaries, pay attention to situations in which you feel stressed. Reflect on the sources of stress related to how you are establishing boundaries. Another exercise in clarifying boundaries is to be aware of feelings of resentment, discomfort, and/or guilt (Gionta & Guerra, 2015). If you experience these feelings within a patient relationship, it is time to reset boundaries. Somatic Awareness Can you identify the physical expression of your emotional discomfort? Somatic awareness refers to the physical feelings and behaviors experienced while working with a patient, such as tightening of stomach muscles, pulling at strands of hair, or crossing of the arms. Silsbee (2008, p. 154) offers the insight that “sensation provides an early warning system of our habits.” There may be times when you are feeling very “relaxed” and you may need to draw your attention to your level of listening and presence. You also have physical manifestations when you are feeling like you are getting into uncomfortable emotional territory. Some people may feel a physical tenseness, while others may clench their teeth or cross their arms. Whatever the reaction may be, it is important to be aware of the somatic feeling in order to make adjustments, such as taking deep breaths or mentally calming yourself for effective APRN guidance and coaching. A technique that may be useful to enhance somatic awareness is using Silsbee's (2008) “body scan” approach. Starting with the feet and, moving up your body, scan for physical responses to a situation. This can be done quickly—in a few seconds. Range of Feelings Are you aware of your comfort level with a wide range of feelings for both yourself and the patient? Being comfortable with the breadth (e.g., anxiety, anger, fear, happiness, sadness) and intensity of your feelings in relation to those of patients is essential to give patients the opportunity to talk about their feelings. If a patient senses your discomfort with anxiety, she will not talk about it. Transformational change for patients occurs at the emotional level, and the APRN coach will only be able to support this by recognizing and accepting his or her own feelings in order to accept those of the patient. A patient with newly diagnosed breast cancer or who is having unexpected triplets will have a range of feelings, and if the APRN is not comfortable with the patient's feelings, the patient will feel inhibited to share those feelings. To get a better understanding of one's own feelings when interacting with a patient, use root cause analysis applied to the exploration. Create some mental space (between patients) and keep asking yourself why you were experiencing your feelings. This can take you to a deep level toward understanding your feelings. It is also useful to pay attention to triggers. When you note a particular feeling while guiding or coaching, reflect on what might have contributed to that feeling. Courage to Challenge Are you comfortable challenging a patient? The APRN coach must be willing to challenge a patient in order to help move the patient forward. While it is important to maintain a good working relationship, wanting to be liked may interfere with the effectiveness of challenging a patient's view or with interpretation of situations, beliefs, or values. Patients often get “stuck,” and respectfully challenging them to think differently or see themselves or their situation differently can get them “unstuck” (Moore & TschannenMoran, 2010). Challenging patients is a way of deepening awareness and forwarding action by making a request or suspending a belief. For example, a challenge might be, “Could I challenge you to 30 days with no sugar?” or “What would it be like to approach this situation without any fear or anxiety, instead cultivating calm confidence?” One useful way of maintaining an effective APRN therapeutic relationship while challenging the patient is to inquire about feedback. Ask the patient if the conversation was useful, what part was most helpful, and what created discomfort. In challenging, make sure patients know that you are fully with them on their journey and that the point of the journey is to create change. APRN Proficiencies Specific to Coaching Ask Permission Although nursing is a wonderful blend of science, technology, and caring, nurses have a strong drive to make people better, whatever the specific situation. APRNs have embraced the idea of holistic health care and are empathic with patients, but there continues to be an attitude that providers know what is best for patients. Integrating coaching into practice requires a culture shift and a change in personal philosophy and approach to caring for patients. To effectively integrate coaching into personal beliefs as well as the practice culture, there are many small actions that can support stronger APRN encounters. A crucial first step is asking permission from each person prior to initiating a coaching conversation. Asking permission, such as “May I coach you on this?” or “Is it okay for me to explore this with you further?,” is a way of respecting boundaries. Asking permission also demonstrates to the person that he or she has a choice and power in the relationship (Kimsey-House, et al, 2011) . If the patient decides against coaching, the APRN should move to providing guidance as part of basic care. Support Small Changes Although big change is often desired, small changes are what create forward movement. Nearly everyone at some time has intentions to lead a healthier life by making adjustments in lifestyle. Each New Year millions of resolutions fall by the wayside because we try to take big leaps to change behaviors and then realize a big leap is too difficult. When coaching a patient, there is a tendency by both APRN and patient to jump to big interventions. Well-intentioned patients may want to initiate major interventions to manage their health but they overestimate the change they can realistically make in their lives. Overestimating the ability to make lifestyle changes can then be demoralizing when the changes are not successful. Often, a patient will commit to making a change in order to please the APRN but cannot follow through. Having patients consider small changes may produce bigger and more lasting results. According to Seligman (2011), humans are more likely to achieve their goals if they have early success. Success breeds success, with small changes being easier to integrate into a lifestyle. A person trying to lose a few pounds may believe that a strict diet is mandatory, requiring considerable changes, such as how food is purchased and prepared, who does the preparation, limiting food intake, and changing social patterns to adhere to the diet. However, as a coach you can work with your patient to make a small change, such as taking a walk to add exercise or decreasing the amount of liquid low-nutrient calories. Small changes are part of a larger process of change. Patients can be coached to do one intervention, and once that is integrated into their lives, additional small changes can be added. These small changes can add up to major lifestyle changes. Although small changes can have a big impact and are a useful start for lifestyle change, there may be patients who need to decide on a big change in their lives, such as having bariatric surgery to achieve weight loss, or leaving a toxic relationship. Be Curious Perhaps one of the most useful coaching tools is to be curious (Moore & Tschannen-Moran, 2010). Being curious will provide the foundation for asking questions—and likely the right questions. Patients nearly always give clues as to what is on their minds—but may not be direct. One should follow with up with questions such as “I wonder what … means to you?” or “I am curious about what you just said that ….” These very simple questions based on curiosity often net a rich conversation and help bring out issues that are important to patients. In a time-constrained environment, APRNs may feel inhibited from opening any doors to topics that they may not be able to pursue with patients. However, not opening the door deprives patients of being able to talk about what is really important to them, and opportunities to positively impact their life are missed. Getting to the Feelings Change happens when people understand and incorporate the need for change at an emotional level. Although knowledge of data is helpful, it is usually only a starting point because the knowledge alone usually does not create transformative change. In coaching patients, it is important to get to the emotional meaning of their issues (Stober & Grant, 2006). Naming emotional feelings is a driver for motivation to change. Exploring feelings related to change links mindfulness and contemplation to taking action. A universal response to change—even change we believe we should make—is resistance. We create reasons for or exceptions to why we cannot change, such as, “It's too hard,” “I don't really like/need/want to do this,” or “I've tried before and failed.” A major reason for resistance to change is simply fear—fear of not being successful, fear of what other people may think, and many other types of fears. As an APRN, having a trusting relationship with your patients can help them name and understand their fears and other feelings about change. Getting to the feelings has boundaries. This does not mean getting to feelings that relate to psychopathology or feelings related to issues that require counseling. Naming/identifying feelings should not be focused on the past, such as on past relationships with family members, but on the present and future. It is about getting to the feelings related to the present circumstances creating the need for change, the change process itself, and the potential outcome. The following statements can be used to get to feelings: • “Tell me about how you feel when you think about (or talk about)….” • “Knowing how you feel about … is important to me.” APRN Coaching Process Although the skills noted in the previous section are critical to being an effective APRN coach, bringing the coaching process into practice is the foundation of coaching. The process includes assessing the readiness of the patient to engage in change, preparation to make the change, taking action, and finally maintaining the change (Fig. 8.4). FIG 8.4 Stages of change. Patient Readiness In order to be coached, the patient must be functionally able, creative, and resourceful. Therefore most people in the general population are appropriate to receive/participate in coaching. If an APRN is considering using coaching, the patient must first be deemed well enough to imagine a better future for herself. Consequently, coaching will not be productive with people who cannot envision a different future. Explicitly, those who are severely mentally ill, psychotic, manic, severely depressed, suicidal, inebriated, obtunded, demented, or high or who are in a severe emotional state such as acute grief or trauma are not appropriate to engage in a coaching partnership. People with mental illness or in an acute intense emotional state are best engaged with empathy and guidance. A simple way to determine if a person is coachable is to ask the individual to describe his or her life in the future, if everything went as well as it possibly could for her or him. If the person cannot articulate an answer, the APRN should not enter into a coaching dialogue, but instead work with him or her to be able to envision a future, healthier life. After rapport has been developed and some degree of empathy expressed, the APRN must determine the person's readiness for change. The person's stage of change in any given self-defeating lifestyle must be documented in the health record for the entire health care team to use and build on, measure progress, and guide interventions. According to Norcross (2013), only about 30% of the general population seen in health care is in the “Action (making changes)” stage (Fig. 8.5). Staging people is a necessary first step to any coaching encounter because it drives the skilled conversation. Taking the time to assess where the person is in the change process sets the stage for a deeper, more meaningful, and more effective encounter. FIG 8.5 Stages of change. Resistance When people are resistant, they are saying they will not change, they have no plans to change in the near future, or they are wholly not interested in changing. The main task for the APRN in working with people who are resistant to change is to help them feel understood. These interactions need not take a great deal of time, and the patient should leave the APRN with the feeling of being understood, that the APRN “gets me.” The challenge for the APRN is to see how the selfdefeating patient activity serves a larger purpose in the patient's life and to offer a partnership statement for the future, such as “I can see how smoking makes you feel like you are making your own decisions in your life and how important that is to you. If you ever want to quit, come back and we can work together for you to stop smoking.” Specific advice at this stage can drive resisters deeper into resistance. If a patient is not interested in being coached, guidance can be offered as a more passive way for the patient to be engaged. Contemplation APRNs most often see patients when they are in the contemplation phase. It is the place of ambivalence, where they both want to change but do not want to. Advice at this stage can be harmful. Instead, the APRN should determine personal motivators and bring forth the emotional conflict the person is experiencing. The APRN should approach the person in ambivalence with a neutral stance, without pushing. To determine his readiness for change, using questions such as “Why is this important? Why now? What if you did nothing and stay on this course—what is your future like in 10 years?” can move the person to identify personal motivators. The key task in this stage is to arouse emotions and encourage people to start talking about their ambivalence. Preparation Once a patient moves to the preparation phase, the task of the APRN is to identify barriers and develop remedies for these obstacles in partnership with the patient. With many life changes, it is important to set a start date and prepare the environment for change, such as finding an exercise partner or identifying impulse control techniques. Suggestions, gently offered, can be helpful in this stage as long as the APRN has no strong ownership in the person's willingness to adopt a specific suggestion. Action Action is when the patient is actively engaged in making a lifestyle change. This stage is one in which direct advice and guidance is most helpful. Brainstorming on strategies to overcome obstacles and what to do in the event of a short-term lapse (a one-time re-emergence of an unwanted behavior) or relapse (fully reverting back to prior behavior) are important conversations. A common technique is to create “if, … then” scenarios. For example, if a patient was working to reverse her or his type 2 diabetes and was excluding sugar from his or her diet, she or he could plan that if he or she ingests sugar, then she or he gets right back to avoiding sugar at the next meal. Anticipating setbacks and having remedies planned for lapses and relapses are crucial during the action stage (Norcross, 2013). Maintenance Maintenance often requires the APRN to acknowledge the patient's success, and to ask about how the patient holds himself or herself accountable, how he or she manages lapses, and what he or she would do if a relapse occurred. When a patient experiences a full relapse, she or he reverts to consistently exhibiting old behaviors. The APRN must determine where the patient is in the cycle of change again (e.g., are they in resistance vs. contemplation, or are they back in action?). It is important for the APRN to approach change as a process and to be aware that having setbacks can be common for some people. The “Four As” of the Coaching Process According to Rogers (2012), coaching is a partnership of equals whose aim is to achieve speedy, increased, and sustainable effectiveness through focused learning on some aspect of the patient's life. Coaching raises awareness and identifies choices, with the APRN coach and patient working from the patient's agenda. Together they have the sole aim of closing the gap between performance and potential. A crucial first step is asking permission from each person prior to initiating a coaching conversation. As noted previously, it is important to get permission from the patient to move into coaching mode. Initiating a coaching conversation differs sharply from shared decision making (discussed in Chapter 7), in that APRNs hand control almost entirely over to the patient in coaching. Once the APRN determines that the person is appropriate for coaching, a four-step coaching methodology—agenda setting, awareness raising, actions and goal setting, and accountability—is followed in sequence (Fig. 8.6). FIG 8.6 The “four As” of the coaching process. Agenda Setting Agenda setting, and the broader coaching methodology, requires handing over control and the choice of topic to the patient. The APRN elicits the agenda (the topic the patient wants to discuss) from the patient and the APRN and patient work together to address the patient's agenda. For example, the APRN may say, “You have a lot of things going on with you and we have 15 minutes together today. What would be most useful for you to have accomplished when our time together is done?” Allow for silence because this is a powerful question in and of itself. The patient may struggle with that question, and the APRN may need to ask more probing questions; however, the agenda must be specific, measurable, and within the patient's control. Agendas cannot be centered around feelings or the actions of others. Acceptable agendas could include, “I need a plan for managing sugar cravings” or “I want to be able to manage the colostomy myself,” while unacceptable agendas are “I want to feel better” or “I want my wife to have more concern about my pain.” Eliciting and clarifying the agenda is a necessary and important step in the coaching process. If no agenda is determined by the patient, then no coaching can occur (Kimsey-House et al., 2011). Focusing on the patient's agenda is a sharp departure from what is typically provided by APRNs in the form of patient education because the encounter is entirely directed toward what the patient wants. The decisions each person makes, no matter how small, lead him toward (or away from) a life that is healthier. Thus at some level, the patient agenda is wrapped in the person's fundamental values and truth. Awareness Raising Awareness raising requires challenging the patient's mindset and assumptions about an issue with which she is struggling. It requires skillful inquiry in which the APRN adopts a highly curious approach to understand what and how the patient thinks about an issue. Awareness is raised by asking powerful questions (Table 8.3) that have likely never been asked of the patient and require deep reflection. This phase of coaching generally is the most time consuming. As the APRN builds coaching skills, it can be helpful to have five powerful questions that are used regularly to begin an inquiry. During the awareness phase, the APRN is using deep listening skills, watching for nonverbal messages. The APRN may become aware of the moment in which the patient has a major insight or makes new connections. The APRN can identify when awareness has been raised because there may be more silence and the patient will begin to identify changes he or she wants to make. TABLE 8.3 Coaching Phases, APRN Skills, and Examples of Questions for Patients Coaching Phase APRN Skill Examples Agenda elicited Excavate what is most meaningful Clarify needs What is most important/meaningful/helpful to you at this time? What do you need from our time together? Awareness raised Ask powerful questions Shift consciousness What are you not willing give up? If you say “YES” to X, what do you say raised Shift consciousness Let the person do most of the talking Explore assumptions with curiosity Promote “generative moments” If you say “YES” to X, what do you say “NO” to? What's working well in this situation? Who do you need to become to make it happen? What do you want to see happen? What do you want to be held accountable for? What do you most value about yourself? What would your life be like if you were not (name limitation)? What is your deepest desire for yourself? Actions/Goal setting Link raised awareness to specific goals to forward into action Brainstorm Determine self-efficacy Challenge if the person could do more (gently and once) What do you want to do and when do you want to do it? On a scale of 1 to 10, how successful do you think you will be? What is going to get in your way? What is the remedy to that obstacle? Can I challenge you to … (do more)? Accountability Help person use resources, not pursue goals alone Partner with supportive others Use technology Confirm agenda met How do you want to be accountable? What will you do if you go off your plan? What is your “when-then” plan? Did you get what you needed today? Actions and Goal Setting The APRN asks the patient what she or he wants to do and when he or she wants to do it. Goals flow directly from the awareness raised, which arouses emotions, and the patient has a higher degree of selfefficacy in pursuing the goal(s). If the patient seems stuck on developing a solution, the APRN can set up a brainstorming exercise in which the patient and APRN take turns coming up with a list of ideas/solutions. The key competency in brainstorming is to not allow the patient to judge the ideas until they are all laid out. Once the goals or actions are determined, the APRN must determine self-efficacy (the belief a person has in herself or himself to complete a task). The APRN asks, “On a scale of 1 to 10, how successful are you likely to be in doing this (10 = success)?” If the chosen number is less than 7, the goal must be modified. Success breeds success, so as any adult embarks on a change process, it is important to have early successes. During this phase of the coaching, the APRN is letting the patient talk. The APRN may need to ask clarifying questions to make the patient's goal more specific. If the APRN has a sense the patient could do more, he or she can challenge the patient. This skill is only used during the goal-setting phase and when the APRN thinks the patient could do more. For example, if the patient commits to ambulating down the hall once a day, the APRN can challenge him or her to do so 3 times a day. The patient will respond to the challenge in one of three ways: (1) agree to it, (2) reject it, or (3) modify it. It is crucial that the APRN accepts fully however the patient responds and challenges the patient no further. Accountability The final step in the coaching method is determined by the APRN asking, “How do you want to hold yourself accountable?” Ideally, it is best to use the patient's own resources to achieve accountability, such as relatives, coworkers, or apps. The APRN could offer himself or herself as a way to hold a patient accountable, but it must not present any burden to the APRN. Accountability could be in the form of an email, text, or follow-up visit. It is important in this phase to have the patient outline a plan if the goals are not being met; this may include developing “when-then” strategies such as “When a week goes by and I haven't done what I said I would, I will reschedule with you” (Rogers, 2012). The Dilemma of Guiding or Leading From Behind Shifting into APRN coaching practice will require the APRN to learn when coaching will be useful and when patient education is most appropriate. Health care information is now easily accessible, and social networks such as PatientsLikeMe (www.patientslikeme.com) significantly alter the needs of patients. An increase in customization, translation, and wisdom is needed for patients who have difficulty seeing their way forward. Applying the right intervention at the right time for patients receptivity to change is critical. The right intervention may likely be a combination of guidance and coaching. Building Coaching Into Practice Although building coaching into APRN practice is largely based on integrating the skills and mindset of coaching as a way of relating to patients, there are small things that the APRN can do to integrate coaching into practice. Some examples of building coaching into the structure and process of care include: • Collecting information from patients while they are in the waiting room or waiting in the examination room that is related to their goals for the visit. Questions on an intake form could include: • What are your current goals for maintaining or managing your health? • Do you feel you are committed to pursuing these goals? • What makes these goals important to you now? • Focusing on the patient's goals and ask what would be useful from the APRN to move toward achieving those goals. • Establishing a section in the medical record that summarizes the patient's goals, actions, and follow-up plan. If using an electronic health record, there may need to be negotiation with the service provider to integrate this information into the record. • Creating a safe and welcoming environment in the examination rooms using pictures, soft colors, and other visuals that are comforting. There are several useful resources that include sample coaching contracts, exercises to practice skills, and other useful materials (Donna & Wheeler, 2009; Dossey et al., 2015; Hudson Institute, 2016). Conclusion Guidance and coaching are effective, rewarding, and critical skills to bring to patient care. APRNs are providers who have already integrated the value of patient-centered care, and guidance and coaching brings the focus of care to the patient's goals, preferences, and abilities. Guidance is different from coaching in that it is directive and values patient education. Guidance relies on the APRN as the expert. Coaching is focused on goals established by the patient and assists the patient to understand and use his or her capacity to achieve those goals. Although many APRNs have built guidance and coaching into their practice, there is a need to have all APRNs examine their mental model of interacting with patients to build on the guidance and coaching processes and skills and partner with patients to help them create healthy change. Guidance and coaching are necessary skills for all APRNs. 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Pearson Let us never consider ourselves finished nurses… we must be learning all of our lives. —Florence Nightingale CHAPTER CONTENTS Consultation and Advanced Practice Nursing, 204 Defining Consultation, 204 Caplan's Definition of Consultation, 205 Differences Between Consultation, CoManagement, Referral, Supervision, and Collaboration, 208 Model of APRN Consultation, 209 Ecologic Field of the Consultation Process, 209 Purposes and Outcomes, 209 Process for Formal Consultation, 210 Other Models of Consultation, 215 Standards of Practice, 215 Applicability of Benner's Concept of Expert Practice to Consultation, 215 Common APRN Consultation Situations, 216 APRN-Physician Consultation, 216 APRN–Staff Nurse Consultation, 217 Consultation in the International Community, 217 Issues in APRN Consultation, 218 Developing Consultation Skills in APRN Students, 218 Using Technology to Provide Consultation, 219 Documentation and Legal Considerations, 220 Discontinuing the Consultation Process, 221 Developing the Practice of Other Nurses, 221 APRN Consultation and Research, 222 Billing for Consultation, 222 Evaluation of the Consultation Competency, 223 Obstacles to Successful Consultation, 223 Conclusion, 223 Key Summary Points, 224 The author wishes to thank the following authors of previous chapters used in the writing of this edition: Anne-Marie Barron, PhD, RN, PMHCNS-BC, FNAP; Patricia A. White, PhD, ANP-BC; Julie VositSteller, DNP, FNP-BC, AOCN; and Allison B. Morse, ScM, ANP-BC, WHNP, AOCNP. Consultation is an essential part of the advanced practice registered nurse (APRN) role. It is both a skill and an art and requires knowledge, experience, and an integration of the essential aspects of the APRN role that are brought into clinical practice. The evolution of the APRN role, supported by the Institute of Medicine report, The Future of Nursing (2011), has resulted in parallel development of consultation as a required competency for APRNs. This has increased professional attention toward the specific competencies required to provide consultation. Historically the nursing literature on consultation focused most on the clinical nurse specialist (CNS) role. As advanced practice nursing has evolved, the consultation competency has received more attention and is explicitly addressed as a role expectation for all four APRN roles. The American Association of Colleges of Nursing (AACN, 2006, 2011) has highlighted consultation as an essential component of master's and Doctor of Nursing Practice (DNP) programs. In defining the essentials of DNP education, the AACN emphasizes the need for explicit skills in the areas of collaboration and consultation for DNPprepared advanced practice nurses. While acknowledging that the roles in any specialty nursing practice have overlap and differences, consultation activities for all are essentially the same process with varying specialty content emphasis. The complexities of today's health care settings require that all APRNs offer and receive consultation and understand, clinically and legally, the differences between consultation and collaboration. At this time in nursing history, with advanced practice nursing skill development and political support, APRNs are poised to provide consultation to patient populations and systems with the power to change the quality of health care. The Institute of Medicine's landmark report, The Future of Nursing: Leading Change, Advancing Health (2011), cemented the role of nursing in transforming the health care system in the United States. This report, along with the Patient Protection and Affordable Care Act (2010; Carthon, Barnes, & Sarik, 2015), focus attention on new health care delivery and payment models that emphasize teamwork, care coordination, prevention, and value. Nurses are contributors to the health care system at all these levels of health care. The process of consultation is integrated into each. The purpose of this chapter is to define consultation in APRN practice, explore theoretical models that have defined this activity, and distinguish the process of consultation from other APRN activities, including supervision, collaboration, and co-management. These activities have different meanings, outcomes, and responsibilities. The specific definitions of consultation originally posed by Caplan (1970) and later by Lipowski (1974, 1981, 1983) and Barron and White (2009) form the theoretical underpinnings for this chapter. The author of this chapter has been a psychiatric APRN for over 35 years in many capacities—as a practitioner, educator, journal editor, and consultant. This chapter reflects this experience and lessons learned from errors and mistakes. Theoretical models have endured, adapted to more current practice, and positively guided the interprofessional practice of consultation. Consultation and Advanced Practice Nursing Consultation has been a key part of the APRN role since the role was first conceptualized. The 1960s marked an increase in graduate training for specialty advanced practice roles. In the United States this was facilitated by increased federal funding for graduate nursing education (Hoeffer & Murphy, 1984). By 1980 the American Nurses Association had developed a social policy statement that defined and supported specialization of advanced nursing practice (American Nurses Association, 1980). When the predominant advanced practice role was the CNS designation, the course content around consultation was “embedded in the clinical practice aspect of educational preparation” (Pearson, 2014, p. 270). This embedded clinical role was furthered by increasing visibility of role models and more defined actions encompassed in the consultation process. Benner's model of expert nursing practice (1984) formed the basis of Fenton's work (1985) that defined the CNS consultation role as a specific practice domain. This was characterized by patient care consultation to nursing staff, interpreting the role of nursing to other professional staff, and providing patient advocacy by consulting to staff treating complex patients and families. Fenton was one of the first nurses to describe advocacy as a fundamental aspect of consultation. By embracing this, APRNs are able to differentiate their consultation role from that of other health professionals. The overarching principle of consultation has to be the element of caring, essential to all nursing practice. From this comes the specific process providing expert information about a particular situation, health issue, or patient or staff issue. State laws and regulations may mandate a “consultative” or “collaborative” role with a physician for advanced practice and prescriptive privileges; awareness of statutes and norms that regulate practice is essential for each APRN. The wording of these regulations may imply a hierarchical relationship between the APRN and physician. APRN consultation, as it is described here, is not dependent upon a physician and comprises an independent activity. The goals and outcomes of consultation are relevant to ongoing efforts to reform health care. APRNs can help bring about the national goal of high-quality, cost-effective health care for every American. Consultation creates networks with other APRNs, physicians, and other colleagues, offering and receiving advice and information that can improve patient care and APRNs' own clinical knowledge and skills. Interacting with colleagues in other disciplines can enhance interprofessional collaboration while shaping and developing the practices of consultees and protégés. This indirectly and significantly shapes the quality, depth, and comprehensiveness of care available to patient populations and their families. Consultation offers the APRN the opportunity to positively influence health care outcomes beyond the direct patient care encounter. Defining Consultation The term consultation is used in many ways. It is sometimes used to describe direct care—the practitioner is in consultation directly with the patient. It may be used interchangeably with the terms referral and collaboration, which are actually different activities. Thus, how the term is being used in a given situation may be unclear, and it may be difficult to determine exactly what is being requested and what is expected. A lack of clarity about the specific process being used for clinical problem solving leads to confusion about roles and clinical accountability. The more precisely the word consultation is defined, the more likely consultation will be used for its intended purposes of enhancing patient care and promoting positive professional relationships that result in true collaboration and optimal patient outcomes. Because consultation is a core competency of advanced practice nursing, this precision is needed for communication within (intraprofessionally) and outside of nursing with other professionals (interprofessionally). It is extremely important to understand the differences between consultation and other types of professional interactions. Table 9.1 summarizes these differences, which are further described in the remainder of this section. TABLE 9.1 Adapted from Barron, A. M., & White, P. (2009). Consultation. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach (4th ed., pp. 191– 216). Philadelphia: WB Saunders. Caplan's Definition of Consultation The term consultation has many definitions for APRNs working in a variety of clinical specialties. Although Caplan originally defined consultation as it applied to mental health, his interdisciplinary tenets about the types and process of consultation have endured and have applicability to all APRN specialties. At a broad level, consultation is defined as “any professional activity carried out by a specialist” (Caplan & Caplan, 1993, p. 11). At the other end of the definition continuum, consultation has very specific and strictly applied parameters. Consultation was specifically defined by Caplan as an indirect service model that involves “a process of interaction between two professionals—the consultant, who is a specialist, and the consultee, who invokes the consultant's help in a current work problem that he believes is within the consultant's area of specialized competence. The work problem involves managing or treating one or more clients of the consultee, or planning or implementing a program to cater to the clients” (Caplan, Caplan, & Erchul, 1995, p. 11). Other principles of consultation include: 1. The client is the layperson who is the focus of the consultation. 2. The consultant is not responsible for implementing interventions or remedial actions. 3. The consultee continues to have professional responsibility for any corrective action. 4. The consultee is free to accept or reject any of the consultant suggestions. For purposes of this discussion, the “layperson” defined by Caplan could be any individual for whom the consultee requests consultation. This could be a patient, a client, another nurse, or other health care providers. Realistically APRNs are often asked to consult in situations in which the parameters of their influence and authority are less clear when compared to physicians or other health care professionals. Reallife consultations are rarely neatly compartmentalized. The principle of maintaining boundaries around identified responsibilities and roles has merit, and the consultation might be clearer for all involved in the process if there is adherence to guiding principles. Additionally, Caplan (1970) has identified four major types of consultation: client-centered and consultee-centered case consultation and program-centered and consultee-centered administrative consultation. They are discussed here from a nursing perspective. Client-centered case consultation is a traditional type of consultation typically occurring when a generalist asks a specialist for an expert opinion about a particular case or patient. An additional unspoken goal can also be to further the knowledge of the generalist about a particular clinical dilemma that can be generalized to other patient populations or cases. APRNs frequently receive these types of consultation requests in all settings. They tend to be uncomplicated and rely on the nurse's expert clinical knowledge. Exemplar 9.1 represents a client-centered case consultation. Exemplar 9.1 CNS-to-ICU Staff Consultation on a Young Man With an Overdose A young man was admitted to the intensive care unit (ICU) after ingesting acetaminophen as part of an overdose. He had been drunk the night before and had revealed to his mother that he had overdosed on the acetaminophen but his mother had not believed him and told him to go to bed and “sleep it off.” When he became violently ill the next day, she rushed him to the emergency department. He was later transferred to the ICU. This was nearly 12 hours after the overdose. Immediately the psychiatric service and liaison clinical nurse specialist (CNS) were consulted to assess his current suicidal risk and to make treatment recommendations. The young man's mother was distraught and upset that she had not believed him when he told her he had taken the bottle of acetaminophen. The gastroenterologist was not optimistic that liver failure could be prevented given the length of time from ingestion to hospitalization. The psychiatrists assessed the patient to no longer be at imminent risk of suicide. Everyone involved was deeply distressed by the tragedy. The nurses requested that the liaison CNS be available for additional supportive care for the patient, support and referral for the family, and assistance in planning nursing care for the patient. Within 36 hours of admission the patient had slipped into a coma and appeared to be dying. His mother accepted referral to a local mental health center. This was arranged by the consultation liaison nurse. A day later the mother, who had been a constant presence in the ICU and had been verbal about her guilt, regret, and pain, stopped coming to the unit. She said it was too painful to see him in a coma. His friends and other family members were with him constantly as he slipped farther and farther into a coma. All talked continually with the nursing staff and consultation liaison CNS. When Friday evening came the CNS invited the nursing staff to call her if they needed her over the weekend. They called her later that night and said they were concerned about his mother, who had come to the unit to say goodbye to her son. The CNS came in and was present with the family and friends as he died. His mother left, and as the young man passed away, his friends and family were with him. They sang songs and held his hands during the vigil. The CNS and nursing staff remained nearby and ensured that the death was peaceful. This client-centered consultation focused primarily on the needs of the patient and family. The consultant and staff regularly shared their own feelings of impotence and despair with one another as they discussed the care of the patient. That sharing and planning helped shape the nursing perspective in the situation and clarify the goal of promoting a peaceful and comfortable death, once cure was no longer a viable goal. The consultation contributed to an active and compassionate nursing presence in the midst of tragedy and pain. Consultee-centered case consultation also involves focus on improving patient care, but the emphasis is focused directly on the consultee's difficulty in handling the situation. The focus of the consultant is on better understanding the consultee's difficulties and helping that person clarify and correct the problem in a particular case. The goal is education of the consultee, using questions as a springboard for teaching and improved understanding of the patient and the situation. The focus is on the task and on knowledge development. Thus the consultant may educate the consultee further on the issues presented by the patient or may suggest alternative strategies for dealing with the problem. This is probably the most common type of consultation sought by APRNs. The consultant may seek to bolster the confidence of the consultee in handling the problem if, in the opinion of the consultant, the consultee has the ability and potential to do so. If the problem presented by the consultee is a lack of professional objectivity, the consultant can help the consultee identify the factors interfering with the consultee's ability to see the patient realistically. The consultee may hold a stereotyped view of the patient, or perhaps the patient's difficulties in some way mirror or symbolize the consultee's personal difficulties and cloud the consultee's ability to see the reality of the situation. This type of consultation has been an important aspect of traditional CNS practice (Exemplar 9.2). Exemplar 9.2 NP-to-CNS Consultation for a Disabled Man Living in the Community Mr. P is a 49-year-old man residing in a group home. He is considered intellectually challenged with an IQ in the mild range of disability. He also has a seizure disorder requiring daily medications and frequent laboratory monitoring. He attends a sheltered workshop 5 days a week and manages his activities of daily living but needs supervision for cooking, shopping, and managing money. The staff at the group home have noticed that over the past few months he has become agitated and less cooperative. Referred to his primary care provider, a physical assessment ruled out a physical cause to his irritability. The primary care nurse practitioner (NP) sought the consultation of a clinical nurse specialist (CNS) expert in the care of the older intellectually challenged population. The consultant shared clinical experiences in caring for this population and noted the lack of research in the area of behavioral changes in this population. He also recommended a physician colleague whose subspecialty is assessing and treating psychiatric issues in this specific population. In this case, the consultant reinforced appropriate interventions by the primary care NP, offered new ideas for potential interventions, and shared resources for ongoing support, including a physician resource for future needs. Program-centered administrative consultation focuses on a work problem that requires planning and administration and an expert opinion about the development of a new clinical system to provide care. The goal, similar to the first type of consultation, is to provide expert consultation around a program administrative question (Exemplar 9.3). Exemplar 9.3 Program-Centered Administrative Consultation A federally qualified health center (FQHC) is getting ready to open a new outpatient pavilion in conjunction with an established community hospital. This FQHC interfaces closely with the community hospital and hopes to continue this process with the new outpatient pavilion. A consultation is requested from an APRN with extensive experience in both types of care settings to best plan how to provide optimal continuum of care for a patient population that will receive treatment in both settings. Models of community care, reimbursement, and specific nursing roles are part of the consultation. The APRN has not worked specifically in either of these settings and has no personal investment in the outcome of the consultation other than improved care delivery to an underserved population. Consultee-centered administrative consultation is similar to case consultation but involves a focus on the consultee's difficulties with programming and/or organizational objectives rather than a particular patient. The primary concern of the consultant is to correct difficulties of a consultee or among a group of consultees that interfere with program development and organization. These difficulties could be related to group functioning, leadership issues, authority issues, or role confusion. The goal is to help the consultee develop and implement adaptive behaviors to work within administrative boundaries (Exemplar 9.4). Exemplar 9.4 Consultee-Centered Administrative Consultation Administration is recommending a patient education program for teaching breast health in an inner-city, underserved medicalsurgical unit. To assist in the development of this program, the certified nurse-midwife is asked to consult with the nursing leader of the unit and offer perspective on how the program might be implemented considering the patient population and the ability of nursing staff to facilitate this within the boundaries of their current workload. Differences Between Consultation, CoManagement, Referral, Supervision, and Collaboration It is easy for APRNs to become confused about the subtle differences between consultation, co-management, referral, supervision, and collaboration. Each term suggests specific roles and responsibilities and the process for each is different. Consultation activities can be interprofessional between different professional groups (such as physicians, APRNs, social workers, and physical therapists) or intraprofessional between nurses (such as APRN, staff nurse, or nurse leader). Consultation is also used by APRNs to offer clinical expertise to other colleagues and expertise in program development. Given APRNs' advanced knowledge and assessment skills, and in some cases expansion of the APRN role into areas of specialization, consultation between APRNs can foster improved accessibility, consultation, and timely and potentially improved care for patients without relying on another professional group to provide specialty consultation. In contrast, co-management is the process by which one professional manages some aspects of a patient's care while another professional manages other aspects of the same patient's care. Co-management is not a simple process, especially because it involves a commitment to ongoing, clear, and explicit communication with the other provider; awareness and acknowledgment of differing professional styles; and shared responsibility of clinical care. Referral occurs when the APRN directs the patient to another provider or APRN for specialized care, especially when it is beyond the expertise or scope of the APRN. In a referral the clinician temporarily or permanently relinquishes responsibility for care (or aspects of care) to another clinician, who is likely a specialist, for an opinion or management of part of a patient's care. Referral implies a responsibility to facilitate care to the referrant and ensuring that there is a seamless transfer of care from the APRN to another provider. This transfer could be temporary or a permanent transfer of care, which should be clarified prior to the transfer. In most cases, once the care associated with the referral is complete, the patient will return to the full-time care of the referring clinician. An example involves the pediatric APRN recommending a referral to a psychiatric provider for assessment of complex psychotropic medication needs. The term clinical supervision, as used in mental health practices, describes an ongoing supportive and educational process between a more senior, expert clinician and a less senior, novice clinician. The goals of clinical supervision are to develop the knowledge, skills, selfesteem, and autonomy of the supervisee (Caplan & Caplan, 1993). Unlike the consultant, the supervisor is generally responsible for safeguarding the care of the supervisee's patients and is accountable for the care provided to these patients. Supervision is different from consultation. A consultant is often an outsider of the organization or unit in which the consultation occurs. The supervisor and supervisee are generally in hierarchical positions, whereas the consultant should be neutral in this hierarchy. Although the ultimate goal of clinical supervision and consultation is likely the same (assisting another professional to enhance knowledge, skills, and abilities in patient care), the processes, relationships, and responsibilities are different. APRNs are often confused in practice between consultation and collaboration. Chapter 12 provides a thoughtful definition of collaboration that was first offered by Hanson and Spross (1996): Collaboration is a dynamic, interpersonal process in which two or more individuals make a commitment to each other to interact authentically and constructively to solve problems and to learn from each other in order to accomplish identified goals, purposes, or outcomes. The individuals recognize and articulate the shared values that make this commitment possible. (p. 232) Collaboration is a process that underlies the professional interactions involved in consultation, co-management, and referral. Whatever the nature of the consulting relationship, the APRN keeps the patient at the center of her or his actions; therefore consultation requires collaboration on some level when two professionals come together to meet patient-centered goals. Recruiting other professionals for collaboration organizes support of an interprofessional group, thereby increasing the impact on the patient or problem through the synergy of multiple experts. An example of collaboration may involve a geriatric CNS and palliative care nurse practitioner (NP) participating in a family meeting to discuss goals of care with a frail older patient and his or her family regarding end-of-life wishes, including code status and hospice. It is important to note that the American College of Nurse-Midwives (2011) used the term collaboration to describe the process whereby the certified nursemidwife (CNM) and physician jointly manage the care of the woman or newborn; that is, the terms co-management and collaboration were used synonymously. This definition of collaboration suggests a process that underlies the professional interactions involved in consultation, co-management, referral, and supervision. Therefore in the discussion of consultation, collaboration is assumed to be essential to the process. Model of APRN Consultation Barron (1989) proposed a model of consultation for CNSs that was based on the nursing process and incorporated principles from the work of Caplan (1970) and Lipowski (1974, 1981, 1983). This model, expanded by Barron and White (1996), has evolved into a model of APRN consultation (Fig. 9.1) Box 9.1 presents the principles of consultation derived from the field of mental health (Caplan, 1970; Caplan & Caplan, 1993; Lipowski, 1981) on which this model is based. FIG 9.1 Model of advanced practice registered nurse (APRN) consultation. Box 9.1 Principles for the Model of Advanced Practice Nursing Consultation • The consultation is usually initiated by the consultee. • The relationship between the consultant and consultee is nonhierarchical and collaborative. • The consultant always considers contextual factors when responding to the request for consultation. • The consultant has no direct authority for managing patient care. • The consultant does not prescribe, but makes recommendations. • The consultee is free to accept or reject the recommendations of the consultant. • The consultation should be documented. Ecologic Field of the Consultation Process APRNs tend to have a holistic orientation and understanding of systems theory that enables them to apply this consultation model in practice. At the center of Barron and White's (1996) proposed model are the purposes and outcomes of consultation. Surrounding the center is the ecologic field of the consultation. Consultations are embedded in the context of the specific circumstances surrounding the consultation request, so the ecologic field in which the consultation takes place must be understood in order to provide effective consultation (Caplan & Caplan, 1993). This involves an appreciation of the interconnection and interrelatedness of the systems and contexts influencing the consultation problem and process. Thus the consultation process is an integral part of the ecologic field. The process—in which the consultant evaluates the request, performs an assessment, determines the skills required to address the problem, intervenes, and evaluates the outcome—is expanded in Fig. 9.2, as described later. Other elements of the ecologic field include the characteristics of the consultant, consultee, patient and family, and situational factors. It is assumed that there are reciprocal influences among the purposes, process, and contextual factors that can affect consultation processes and outcomes. Each component of the model is elaborated in the following sections. FIG 9.2 Algorithm for the consultation process. Purposes and Outcomes The purpose of a consultation may be to improve care delivery processes and patient outcomes, enhance health care delivery systems, extend the knowledge available to solve clinical problems, foster the ongoing professional development of the consultee, or a combination of these goals. Consultants should be aware that the purposes for which they have been consulted may contract or expand during the process of consulting. Often, APRN consultants accomplish several purposes at once. If additional purposes and possible outcomes are uncovered during consultation, these should be made clear to the consultee. The consultee may want the consultant's assistance with a patient but does not have the time or interest to focus on his or her own development, which could inform the consultee's problem solving in similar patient situations. Patients may also reveal information that requires a shift in the consultation's focus, purpose, and outcome. Over the course of the consultation, being explicit about the goal or outcome of the consultation is essential if APRNs are to evaluate the impact of consultation on practice. Process for Formal Consultation The algorithm for the consultation process presented in Fig. 9.2 defines the process of assessment and intervention in consultation (Barron & White, 2005). It follows the nursing process of assessment, planning, intervention, and evaluation. The process detailed in this figure suggests a continuous loop through the consultation process conducted by the APRN with continual reassessment and evaluation of outcome. This best reflects the reality of consultation in an APRN practice. Rarely is it a neatly executed, clear process with a definite beginning and ending. Rather, as the APRN role develops and deepens, the consultation process builds on itself to establish credibility, effectiveness, and clarity in the APRN role regardless of nursing specialty. However, with experience and expertise, the process may occur fairly rapidly so that the expert consultant may not be consciously aware of using these steps. In addition, in some situations, the problem for which help is sought is clear cut and the consultation is brief. These types of consultations are discussed later in the chapter. Once a request for consultation has been received, assessment of the consultation problem begins with evaluation of the request itself. An important component of assessment is confirming with the consultee that consultation is, in fact, the appropriate strategy for addressing the problem. At this stage, the consultant and consultee may decide that an alternative process is needed (e.g., a shift to co-management or referral). The consultant confirms that the problem has been accurately identified and falls within the realm of the consultant's expertise and clarifies the nonhierarchical nature of the relationship between the consultant and consultee. The consultant also confirms that the consultee will remain clinically responsible for the patient who is the focus of the consultation. The consultant must remember that the consultee is ultimately free to accept or reject the consultant's recommendations. Once the request itself has been considered, the consultant gathers information from the consultee about the specific nature of the problem. The consultant tries to determine whether the patient has unusually difficult and complex problems (patientcentered consultation) or whether the problem results from the consultee's lack of knowledge, skill, confidence, or objectivity (consultee-centered consultation). Once the request, the nature of the relationship, and the appropriateness of consultation have been established, the consultant focuses on gathering data related to the consultation problem. This may include direct assessment of the patient. The consultant considers the ecologic field of the consultation, which includes the systems and contexts that may influence the patient and family, consultee and staff, and setting in which the consultation takes place. Some requests for consultation are focused and require that the consultant identify aspects of the ecologic field that are priorities for assessment and attention. Others require more comprehensive assessment. The consultant uses available resources such as patient records, direct assessment of the patient, and interviews with staff and family to identify the exact problem(s) that is (are) to be the focus of consultation. This may or may not be the problem for which help has been sought. Some consultation problems are simple and do not require extensive data collection. Others are complex and may require extensive chart review for a long-standing problem or calls to referring clinicians when incomplete data have been provided. The consultant shares the identified problem with the consultee and validates this with the consultee. If part of the problem is the consultee's lack of expertise, the consultant will want to use tact as the problem is identified and discussed. Interpersonal qualities of the consultant are crucial (see later). Once the specific problem or problems have been identified, the consultant and consultee consider interventions that will address the problem(s). The consultant may intervene directly with the consultee by using approaches such as education, assistance with reinterpretation of the problem, or identification of appropriate resources if the problem is the consultee's lack of experience. If the problem results from a particularly difficult patient situation, the consultant may assist with the process of clinical decision making by providing alternative perspectives on the problem and recommending specific interventions. More data may be needed to analyze the situation further, and a decision may need to be made about whether the consultee or consultant will gather more data. If the consultee accepts the recommendations of the consultant, together they negotiate how the interventions will be carried out, and by whom. If the consultant is to intervene directly with the patient, the consultee must understand his or her ongoing responsibility for the patient and agree to the consultant's interventions. Together, they identify additional resources and determine the time frame for the consultation (one time or ongoing). After the intervention, the consultant and consultee engage in evaluation. Evaluation of the success or lack of success of the intervention and overall consultation is essential to the consultation process. If the problem is resolved, evaluation offers an opportunity for review, confirmation of the enhanced effectiveness of the consultee in managing the problem (underscoring the new skills and abilities or understanding of the situation by the consultee), and closure. If problems remain, reassessment offers the consultant and consultee another opportunity for problem solving. Formal Versus Informal Consultations The process of consultation as described is comprehensive and formal. The consultant brings clinical expertise and an understanding and appreciation of the process of consultation to the problem presented. According to the model, the consultant considers all elements of the nursing process in relation to the consultation problem. However, what about the quick questions to the consultant, when what is needed is a piece of information and a brief description of how to apply the information? Are these brief interactions, sometimes called “corridor consultations,” that are related to circumscribed problems true consultations? They are, but the consultant needs to make a conscious decision about responding briefly and simply to the request, considering with the consultee whether a quick response addresses the problem. Sometimes, the problem presented oversimplifies a complex concern that in reality requires a more comprehensive approach. If the consultant and consultee consider the problem together, they can determine whether the quick response is adequate or whether consultation is needed. Conversely, sometimes what is truly needed is a short answer to a clinical question or validation that the approach to the problem is appropriate. Barron and White (2005) offered a cohesive description of the differences between formal and informal consultation. Informal consultations occur spontaneously and can involve a quick question about a patient care or system issue. APRNs provide these types of consultations regularly but need to be cautious and able to decide when a quick answer is not appropriate for a complex problem or when a more planned approach to the problem is warranted. As APRNs move into expert status in their practice setting, they get more requests for consultations. They also become increasingly adept and proficient at quickly responding to consultation requests. The art of the process is being able to quickly differentiate when a simple answer is sufficient or when such an answer only worsens the problem. Informal consultations, which can occur frequently in an APRN's practice, require additional considerations. Guidelines for informal consultations are described in Box 9.2. An example of an informal consultation would be an unplanned discussion of a patient with nursing care questions that occurs during a staff meeting. The meeting is attended by the APRN on the unit, and guidelines are given for planning a more focused and formal consultation for the unit staff. Box 9.2 Guidelines for Informal Consultation • Include a disclaimer to emphasize that the consultation is not a formal consultation. • Keep conversations short. • Frame responses in general terms. • Suggest several possible answers, and note that all depend on the specifics of the case. • Be cautious of evaluating any test results and rendering a specific diagnosis. • Keep communications about a particular patient to a minimum. • Advanced practice registered nurses (APRNs) should document all informal consultations, if not in the medical record, then in their own files. This would include their assessments and recommendations in relation to the informal consultation problem. APRNs need to make well-considered judgments about where and what to document about informal consultations. Adapted from Barron, A-M., & White, P. A. (2005). Consultation. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.). Advanced practice nursing: An integrative approach (3rd ed., pp. 225-255). St. Louis: Elsevier Saunders. Staff nurses sometimes equate this brief type of consultation with consultation in general because they have experienced only this type of consultation with physicians, who quickly impart information and are then off to the next patient. The idea of the roving clinical expert dropping by with tidbits of expert advice is the concept that nonAPRNs can have of a consultant. This is another reason why it is important to make a conscious decision about responding in a brief way to the consultation request. In the informal situation the consultee may not realize that a more comprehensive and thorough investigation of the problem and solutions with the consultant is possible. Also, some clinical situations require a more formal approach to the consultation problem. APRNs should consider the types of problems in practice that require a formal approach and develop a system for integrating nurse-nurse and interprofessional consultations, which make advanced practice nursing skills more visible and extend their knowledge and skills. Characteristics of the APRN Consultant In addition to theoretical understanding, self-awareness and interpersonal skills are essential for the consultant. For a model of consultative practice to be implemented, it is critical that APRNs first value themselves and the specialized expertise that they have developed. One must appreciate one's own skills and knowledge before the possibilities for consultation can be envisioned. The knowledge and skills acquired by APRNs could serve to inform and expand the practices of staff nurses, other APRNs, and health care professionals of various disciplines involved in the care of these patient populations. However, APRNs must first appreciate that they have valuable understanding and knowledge to share. APRNs with expert status can carry large amounts of informal authority and power. This may extend beyond the formal boundaries of their role and make them more apt to be approached for consultation. APRNs have to be knowledgeable about systems, relationships, and change (Barron & White, 2005). In addition, ideally, consultants know themselves well—they are aware of their own personal issues, strengths, weaknesses, areas of expertise and motives. A good consultant must be able to suspend judgment and avoid stereotyping and incorporate the core concept of caring in all communications in their nursing practice. When consultation is sought, a fresh perspective is often needed. Self-understanding allows the consultant to see consultation issues realistically, without prejudice. It is not uncommon for a consultant to step into a highly emotionally charged situation and use self-awareness, understanding, and self-possession to remain objective, clear, and effective. It can be meaningful and helpful for the consultant to have a trusted colleague or supervisor with whom to share and review consultation situations. These discussions can offer support and enhance the consultant's understanding of personal and interpersonal responses to the consultation material. The consultant should also be able to establish warm, respectful, and accepting relationships with consultees (Carter & Berlin, 2007; Perry, 2011). The initiation of a consultation request is often associated with a sense of vulnerability on the part of the consultee, who recognizes that assistance is required to help manage the situation at hand. The consultant must communicate (and sincerely believe) that the problem and consultee are important and worthy of consideration. The consultant must also communicate confidence in the consultee's ability to overcome the difficulties resulting in the consultation request. When the consultant creates a climate of trust and acceptance, the consultee can then be willing to risk vulnerability and genuineness with the consultant. A respectful, trusting connection between the consultant and consultee allows a deep examination of the problem, implications, solutions, and ultimately resolution and learning. An APRN may be the consultee, requesting consultation from a physician or another APRN. As a consultee, the APRN should be able to identify and articulate the nature of the problem for which help is being sought. It may be necessary to clarify the collegial, nonhierarchical nature of the consultation relationship. Before consulting with an APRN colleague or physician, APRNs have likely tried alternative plans or directions based on knowledge of the patient or clinical situation. It is important to relay this information to the consultant planning the approach because it can be useful to the consultation. Dialogue with APRN colleagues and physicians can improve the effectiveness and efficiency of the consultation and can strengthen collaboration among colleagues. In addition to their intrapersonal knowledge and interpersonal skills, APRNs must be competent in the consultative process. Although skill in consultation develops over time, the attributes of the consultant and consultation process described here can help novice APRNs learn to consult with confidence (Carter & Berlin, 2007). Characteristics of the Consultee Requesting the Consultation The consultee identifies a problem that exists in a clinical situation because of uncertainty, complexity, or a lack of knowledge on his or her part and believes that increased knowledge and assistance with clinical decision making would enhance practice and patient care. Characteristics of the consultee may need to be considered. Education, experience, the consultee's level of distress regarding the clinical problem for which help is sought, organizational skills, and availability to solve problems with the consultant are factors that can influence the consultation. What prompted the consultation, and how is the request related to specific consultee characteristics? Who is asking for the consultation, and is this person in a position to implement consultant recommendations? Understanding the ecologic field of the consultation involves knowing the APRN role in the situation, identifying the person requesting the consultation, and understanding involved patient/family factors as well as the situational factors that influence the process (Barron & White, 2005). Patient and Family Factors Among factors to consider are the acuity and complexity of the clinical problem, the patient's medical history, social history, social supports, and other resources. Depending on the nature of the problem, it may be important to consider concurrent stresses being experienced by the patient and family. An acute problem may demand the consultant's immediate assistance, requiring a shift in the consultant's priorities. A complex or unusual problem may take more time to solve. Asking the following questions may help guide the process of the consultation: • What is the patient's medical history? • What are the acute and chronic issues affecting the patient's current status? • What family issues are influencing the patient's status currently and historically? Situational Factors Perhaps the most important of all considerations, situational factors are those issues within the organization and staff that influence the consultation process. In this model, the term situational factors refer to those inherent factors in the organization and staff caring for the patient. Numerous situational factors can affect the consultation process. For example, the mood or atmosphere of the care environment, the power differential between different levels of leadership or nursing staff, and professional differentiations between various professional groups all influence the situation (Barron & White, 2005). The quality of relationships and interactions between staff and patients or among staff members themselves may be important issues. For example, a patient perceived as being nonadherent to some therapy may be responding to conflicts among team members that the patient has inferred from clinicians' behaviors. A clinician may seek validation from a consultant as a way of getting support for an unpopular but potentially productive approach to a clinical problem. Time pressures and lack of adequate resources can affect consultation. Organizational factors include legal factors, regulatory considerations, and credentialing mechanisms for a specialty practice. Organizational politics, power imbalances, and rapid or frequent system changes also are to be considered. All these factors can affect the consultee's view of the importance of the request. For APRNs, the status of advanced practice nursing and APRNs in a particular agency or state may influence consultation. For example, organizational policies and procedures regarding consultation and nursing practice, statutes regarding APRN-physician consulting relationships (e.g., required collaborative/consultation agreements versus independent practice), protocol agreements, reimbursement policies, malpractice, and degree of prescriptive authority may all affect the consultation process. Other Models of Consultation Other nurse experts have defined nursing consultation. In psychiatric– mental health nursing, the psychiatric consultation liaison nurse (PCLN) role was implemented as a way to have psychiatric–mental health nurses involved in medical-surgical environments, identifying comorbid psychiatric disorders and the ways that they manifest in patients on the medical-surgical unit. PCLNs traditionally consulted directly with staff, but also with managers in health care systems, around organizational issues and administrative concerns. The PCLN role has been in existence for nearly 50 years to offer: immediate, short-term, crisis-oriented mental health intervention and education to individuals in medical-surgical settings, to bridge the gap often found between psychiatric and medical-surgical nursing care, and to facilitate clients' transition to additional health services of both a physical and psychosocial nature. (Yakimo, Kurlowicz, & Murray, 2004, p. 215) Similarly, the CNS role has historically had a strong consultation component. Benner's model of expert nursing practice (1984) further informed the CNS role in consultation. This included: • Providing patient care consultation to the nursing staff through direct patient intervention and follow-up • Interpreting the role of nursing in specific clinical patient care situations to nursing and other professional staff • Providing patient advocacy by sensitizing staff to the dilemmas faced by patients and families seeking health care These concepts, while linked more specifically to CNS functioning, have applicability to all APRN roles. Barron and White (2009) evaluated the differences between consultation and other APRN practices. Few APRN staff function only as consultants because this competency is most likely combined with other aspects of APRN practice. Acknowledging and defining the role activity at the time it is being performed is the responsibility of the APRN. Standards of Practice The Consensus Model for APRN Regulation (APRN Joint Dialogue Group, 2008) was an effort aimed at unifying the different types of advanced practice nurses that were practicing throughout the United States. Standards have been set forth by the National Council of State Boards of Nursing in conjunction with the Advanced Practice Nursing Consensus Work Group. The APRN regulatory model emphasizes consultation activities as part of the APRN's role function (National Council of State Boards of Nursing, 2008). In addition, The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) sets the practice stage for DNP-prepared APRNs to engage in consultation activities as part of their indirect and direct care management of complex health care situations and patient populations. In a similar manner, the National Association of Clinical Nurse Specialists (2004) organizes CNS practice into three domains: patient, nurses and nursing practice, and organizations and systems. This integrated model of CNS practice is referred to as the Spheres of Influence model (Fulton, 2014). The Association identified the consultation competency as a required skill in a CNS role. Historically, consultation in these spheres was the hallmark of a CNS role. Yet the influence of third-party reimbursement and fiscal restraints on the CNS consultation role cannot be underestimated because the demand for third-party reimbursement has escalated and requires justification of a consultation role. Many CNSs have woven consultation into their reimbursement, citing that this work is highly impactful on the health care environment (Pearson, 2014). Many hospitals and clinics eliminated CNS positions prior to fully understanding that consultation could and should be billed. All systems that utilize third-party reimbursement need to ascertain a way to formally bill for consultative services provided by nurses. NP core competencies were updated by the National Organization of Nurse Practitioner Faculties in 2017. Although not formally listed as an NP core competency, the concept of consultation can be indirectly ascertained within each competency. This is in contrast to the CNS competencies, which clearly delineate the consultative aspects of this role. Applicability of Benner's Concept of Expert Practice to Consultation Benner noted that nursing practice undergoes a shift from competent to proficient to expert in the course of experiential role development. Proficient practice is described as: an increased capacity for recognizing whole patterns and a budding sense of salience where relevant aspects of the situation simply stand out without recourse to calculative reasoning. Proficient practitioners can read a situation, recognize changing relevance, and accordingly, shift their perspective on the whole situation. (Benner, Tanner, & Chesla, 2009, p. 137) This proficiency leads to expert practice, which is characterized by the ability of nurses to intuitively understand and respond to the pertinent issues in a situation. Engaging in expert practice makes the process of consultation more effective and easier. Expert nursing practice encourages a broader view of the situation, using engaged practical reasoning. This reasoning relies on a mature understanding and perceptual grasp of the nuances of a particular situation. APRNs at the level of expert practice have embedded knowledge of nursing practice, are engaged in the process, and are able to understand their role definition in the larger health care system while confident they can make a difference in the system to which they are consulting. This is not to suggest that APRNs at earlier stages in their practice are unable to provide expert consultation. It means that as APRNs become more expert in their chosen specialty area, their ability to provide consultation becomes easier and more seamless. The clinical expertise gained from experience translates into increasing levels of confidence in the ability to provide consultation that is thoughtful, intelligent, and clear about professional boundaries, and that ultimately, in many situations, can improve patient care or system functioning. Common APRN Consultation Situations APRN-Physician Consultation Consultation and collaboration with the physician and patient care team remain integral components of APRN interprofessional development. When consulting with other nurses or physicians, an APRN is likely to be far along in the problem-solving process. The need for consultation is often related to the consultee's level of diagnostic uncertainty or complex management issues. Experienced APRNs often have a clear definition of the problem and a preliminary plan to address it that they wish to validate or reformulate, depending on the consultant's advice. Truly collaborative relationships between physicians and APRNs ensure consultation that is bidirectional. Physicians in primary care often consult APRNs regarding issues such as assisting patients in making lifestyle changes or in coping with the effects of chronic illness. Many APRNs in primary care have specialty expertise in women's health care and are sought out by physicians for consultation on such issues. Physicians might then choose to comanage patients with APRNs so that patients benefit from the expertise of both professionals. An APRN, in turn, might consult a physician regarding a patient in a medically unstable condition, which evolves into co-management by the physician and APRN, with each assuming responsibility for the outcomes of decision making. The American College of Nurse-Midwives (2011) was deliberate in describing the various types of interactions that CNMs have with physicians. Unfortunately, APRN-physician consulting relationships have often been structured by laws and regulations that mandate or imply supervisory oversight, which can reinforce stereotypical nursephysician relationships. Many organizational cultures reinforce traditional nurse-physician relationships and the behavioral norms associated with them. One of the major challenges facing advanced practice nursing educators is to fully delineate/explore the APRNphysician relationship to ensure that students understand the autonomous expression of advanced practice nursing. This is key to developing collegial relationships, including use of consultation that is not hierarchical in nature. When a hierarchical relationship exists between an APRN and a physician, the APRN who consults may defer to the physician's decisions, downplaying or ignoring first-hand knowledge of the patient. However, interactions between physicians and APRNs can be extremely successful, and these practices embrace the collaborative relationships that are key to effective consultation (see Chapter 12). Consultation between APRNs and physicians can highlight the strengths of each—that is, the APRN's deep appreciation for the human responses related to health and illness and the physician's deep understanding of disease and treatment. When both areas of expertise are available to patients and their families, truly holistic, comprehensive, and individualized care is offered. As APRN knowledge evolves and deepens, an emerging issue in relation to APRN-physician consultation is the crossing of traditional nursephysician boundaries. As APRNs become more and more specialized, the knowledge embedded in practice may be more closely related to what is generally thought of as medical practice. For example, a certified registered nurse anesthetist may have highly developed skills in the area of pain management and the requisite skills to perform procedures to address complex pain issues. In women's health practices, APRNs may specialize in using complementary therapies for menopausal symptoms. Physicians often refer interested patients to the collaborating women's health APRN in the practice for consultation about using complementary therapies. Tact and understanding of the long-standing boundaries that are being crossed can elevate the consultation relationship to a new level. APRN–Staff Nurse Consultation Early on, as CNSs implemented their consultative roles, it became apparent that the culture of nursing had not adopted consultation as an important strategy in providing patient care. Staff nurses were expected to take care of the patients by themselves. A novice nurse might consult a head nurse or more senior nurse, but staff members were expected to know how to solve problems and use the policy and procedure manual. An important component of implementing consultation means teaching staff members how and when to consult. Early on, CNSs often engaged in active case finding to identify patients who needed the knowledge and skills they had because CNSs were not actually assigned to patients and staff nurses. By building this type of clinical caseload, they demonstrated to nursing staff how intraprofessional consultation might be helpful. This process may still occur when an APRN is new to a unit or program, when trust needs to be established with staff nurses, or when an APRN role is entirely new to a unit or organization and staff nurses are unclear what to expect of the new role. Of note, CNSs tended to carry out direct consultation with patients and to consult with other professionals to assist the staff with problem solving and enhancing patient care. For example, staff nurses might call the Adult-Gero CNS regarding a patient with Guillain-Barré syndrome because they have no experience caring for patients with this disorder. The CNS may have had little or no experience as well but can mobilize the resources needed, such as arranging an in-service consultation by the neuroscience or rehabilitation CNS or NP, providing articles, being available to staff on all shifts as they implement unfamiliar assessments, and assisting with care plan development. The APRN initiates processes (including additional consultation) and provides knowledge directly. Once relationships are established and staff members perceive that the APRN consultant is approachable, respectful, and helpful, staff will initiate contact with the consultant when complex clinical issues arise. Exemplar 9.1 presents an example of a consultation resulting from staff nurse identification of care needs. This example demonstrates evolution of the consultation process. The APRN has specific clinical expertise and is called on to support the ICU nursing staff in managing a complex overdose patient. Nursing staff are provided with evidence-based practice knowledge around mental health issues, including suicide risks, death and dying, and family care. Consultation in the International Community The APRN role as a consultant has applicability internationally as evidenced by literature from Switzerland (Bryant-Lukosius et al., 2016), Taiwan (Lu et al., 2016), and Australia (Fry et al., 2013). The increasing recognition of the APRN role as key in health care prevention and provision is prominent around the world. Consultation is one of numerous competencies required in all APRN roles. Within the past 15 years, there has been increased success in establishing international consultative relationships in nursing. The role and use of consultation internationally has expanded, especially in the areas of midwifery (Vosit-Steller, Morse, & Mitrea, 2011) and palliative care. Vosit-Steller and coworkers (2011) reported that with the support of agencies such as Sigma Theta Tau International and the International Council of Nurses, cross-cultural consultation has grown to provide more advanced nursing care to many developing areas of the world. International consultation is challenging and rewarding. The creation of sustainable international collaborations that attend to consultation is congruent with the mission and values of nursing and the philosophy of nursing education (Vosit-Steller et al., 2011). Consultative relationships must initially be built on trust and a common mission, with a commitment to establishing a relationship. Once rapport and appreciation for cultural differences have been established, effective communication in international consultation can be achieved by personal visits, telecommunication, video conferencing, and written vehicles for collaboration. Consultation is a dynamic process that benefits both parties when they understand one another's needs (Exemplar 9.5). There is a current need to expand consultation in the areas of training resources in primary care and specialty areas, to expand education traditionally and through telehealth, and to offer support in utilizing research and writing for publication (Vosit-Steller et al., 2011). Soeren, Hurlock-Chorostecki, and Reeves (2011) noted that the international expansion of the NP role has contributed positively to both intraprofessional and interprofessional utilization of the expertise provided by APRNs. They noted that the capacity to perform holistic care for patients is not limited by traditional role boundaries. Exemplar 9.5 American APRN–Romanian Registered Nurse International Consultationa Mrs. P is a 60-year-old widow who has lived all of her life in Romania. She is Christian Orthodox but does not practice her religion. She receives a modest pension from the government, which meets her financial needs. Her past medical history includes cardiovascular disease. Mrs. P was diagnosed with breast cancer this year and was treated surgically. Following her mastectomy, she refused chemotherapy and radiation therapy. Several months after the mastectomy, she presented with metastatic disease and a fungating breast lesion. The major concerns of the Romanian nurses were related to ineffective control of the drainage and foul odor and the patient's perception of her body image. As they changed the patient's dressing at her home, the Romanian nurse described the current approach to Mrs. P's management to the American advanced practice registered nurse (APRN). The nurse irrigated the area with povidone-iodine (Betadine) and saline and applied a wet gauze dressing. Then petroleum jelly (Vaseline) and crushed metronidazole tablets were applied to reduce odor and prevent infection. Calcium alginate was applied to the edges of the wound to assist with hemostasis. The APRN consultant prepared for the consultation by considering the following questions: 1. How would we manage this type of lesion in the United States? 2. What type of dressings are used in Romania, and why? 3. What solutions are used for irrigating? 4. How can our (US) practice suggestions translate to resources available in Romania, and are there cultural implications? 5. How can nurses communicate with patients with poor body image and compromised sexuality? 6. How do you extend care to family members to inform them about the challenges? The management issues that were raised for input from the APRN consultant included the fact that the wound soaks through the dressing, requiring dressing changes twice daily and resulting in maceration of the wound edges. This then required large amounts of absorbent material and diapers to assist with the drainage. The APRN offered several recommendations regarding how to optimize use of dressings considering the materials and medication solutions at hand in Romania. There was an interactive discussion at the bedside and debriefing following the visit regarding the exploration of which interventions would be useful. The Romanian nurse noted that it was difficult to obtain some of the materials on a consistent basis, such as zinc oxide or alternative dressing materials. Recognizing the limitations in accessing materials for symptom management allowed the consultant to identify areas of creative management, which provided care that was redirected and evidence-based. The eventual outcome was equivalent to using materials that were suggested and available in the United States. a The author is grateful to Julie Vosit-Steller, DNP, FNP-BC, AOCN, and Allison B. Morse, ScM, ANP-BC, WHNP, AOCNP, for this exemplar. Issues in APRN Consultation Developing Consultation Skills in APRN Students For APRNs to learn the theoretical and practical issues involved in the development of consultative abilities, relevant content must be included in graduate education curricula. In highlighting consultation as an essential aspect of DNP education, the AACN (2006) recognized consultation as a central competency for all APRN practice. In addition to faculty-initiated experiences with consultation, APRN students have much to offer each other as they move through DNP programs. Consulting with peers on challenging clinical issues offers students experience with the consultation process as they begin to think of themselves as consultants. Learning how to evaluate and consider the implications of consultation related to the outcomes of care can be valuable for students. Focusing on the impact of APRN consultation illuminates documentation issues, cost-effectiveness, and related curricular needs. These findings could translate to insurers and policymakers who determine policy and payment for health care services. Developing comfort and skill with seeking, providing, and evaluating consultation is an important goal for DNP education. APRNs are expected to influence patients, other providers, and the systems in which they work. Therefore, when APRNs graduate, they should be equipped with knowledge, skill, and confidence in the consultation process. Effective consultation, whether it is sought or provided, enables APRNs to establish credibility, build collaborative relationships with other members of the health care team, and influence the processes and outcomes of care. Using Technology to Provide Consultation The use of new technologies to enhance care delivery has affected every aspect of the health care delivery system. Consultation is now not limited to the physical setting. Teleconferencing has been used successfully in consultation, medical education, supervision, and simulation (Flodgren, Rachas, Farmer, Inzitari, & Shepperd, 2015). In addition, educational models are teaching nursing students how to implement and utilize telehealth models to connect, collaborate, and consult with nurses and other health care specialties providing care (Gray & Rutledge, 2014). The use of technologies in these models of care and consultation are challenging reimbursement, liability, and the definitions of technology-enhanced interprofessional collaboration. This requires clarity about the definition of precise telehealth activities and an understanding of legal and ethical issues related to access, privacy, confidentiality, security, jurisdiction, and licensure standards for APRNs. These differ by state and by practice institution and have to be clarified depending on the geographic location of the practice. Several programs have been implemented using APRN consultation and telehealth. Miller and colleagues (2008) assessed consults completed in the emergency department by APRNs over a 1-year period. The APRNs tended to minor injuries with the assistance of a telemedicine network, if necessary. Of these consults, 60% were found to be appropriate for APRNs (Miller et al., 2008). This figure increased to 84% if children younger than 14 years and those with shoulder injuries were excluded. Schweickert and colleagues (2011) provided a rural, high-risk population access to telehealth stroke education. The program was found to be equivalent to in-person stroke education with regards to satisfaction, knowledge, and making health behavior changes to reduce vascular risk. A team of CNSs has been gathering clinical data from the electronic health record (EHR) about falls, delirium, and the use of restraints prior to consultation with geriatric patients (Purvis & BrennyFitzpatrick, 2010). They are using these computer-generated, high-risk indicators to facilitate nursing practice guidelines, nursing plans of care, and real-time indicators prior to consultation (Purvis & BrennyFitzpatrick, 2010). Some of the care provided by APRNs in retail clinics, minor emergency areas, and rural health clinics can be carried out within the digital arena (Lee, 2011). APRNs have branched out beyond triaging patients in call centers. In a California study, nurses used interactive audio and visual systems to collect and transmit vital signs and provided “palliative care, rehabilitation, and chronic disease management” to patients suffering from HIV/AIDS (Lee, 2011). During a 4-month period, telehealth monitors were placed in patients' homes and, at the end of the trial, patients reported being satisfied with their care. Midwestern Veterans Affairs Medical Centers have created a link through teleconference and electronic medical records. The collective bariatric surgery departments conducted initial consultations through this system for patients who resided at distances of more than 300 miles away (Sudan, Salter, Lynch, & Jacobs, 2011). The satisfaction rate for patients who used the system was 82%; the rate of surgical outcomes and satisfaction was 96.6% (Sudan et al., 2011). Wright and Honey (2016) described a teleconsultation process in New Zealand that sustains the coordination, advocacy, and support of patients and caregivers on the health care team. It was especially useful for distance consultation by specialty nurses. This qualitative research found that teleconsultation provided for more timely care for patients by increasing the access to specialist expertise. The program represents a shift to a technological model that allows patients to remain in their community. Telehealth has also been used in transcultural consultation on palliative care between APRNs in an established collaborative relationship among Brasov, Romania; the University of Rhode Island; and Simmons College (Gerzevitz et al., 2009). Once collegial and trusting relationships were established, teleconferencing was used among the three sites to consult on difficult cases from a hospice in Romania. Electronic communication presented the opportunity to advance practice methods and provide validation for nursing actions (Gerzevitz et al., 2009). Privacy, security, and access to telehealth create unique, additional ongoing concerns in the world of telehealth and consultation. Documentation parameters for security and privacy and the need for security related to the online sharing of private medical information must be delineated by the system where care is being provided. Providing information through telecommunication across state lines raises concerns about liability and differences in state nurse practice acts regarding scope of practice. Documentation guidelines and protocols should be established for the application of any telecommunication considering confidentiality and security issues in telehealth practice. Reimbursement for telehealth and telehealth consultation regularly occurs in most states. The Patient Protection and Affordable Care Act, signed into law on March 23, 2010, addresses the use of telehealth as a means of delivering efficient and effective health care in the United States (Lee & Harada, 2012). Telehealth has become more mainstream as a care model as increasingly there is reimbursement available for the service. States have a variety of implemented reimbursement strategies for telehealth; not all states incorporate these policies into their Medicaid programs. In spite of this, the Center for Connected Health Policy (cchpca.org) noted that 48 states and the District of Columbia have some form of reimbursement for telehealth in their public programs. Notably, no states are alike in definitions of law or policy (CCHPA, 2017). APRNs are currently leaders in telenursing practice and should be aware of important policy issues to advance the use of telehealth further (Schlachta-Fairchild, Varghese, Deickman, & Castelli, 2010), including consultation. Issues such as technology selection and implementation principles, interstate licensure, malpractice, and telehealth reimbursement are important to advancing telenursing further. In addition, evidence-based strategies for demonstrating caring using technology in patient interactions are key for advancing telenursing in APRN practice. Finally, APRNs should be aware of how telenursing can affect the nursing shortage in the United States, providing access to care irrespective of geographic location of provider and patients (Schlachta-Fairchild et al., 2010). The application of technology in delivering health-related information continues to be studied in terms of process and outcomes. APRNs should consider the potential opportunities that exist to enhance consultation activities with these modalities but should exercise caution regarding their implementation until legislative and policy initiatives related to access, security, and mutual recognition of APRN practice across state lines are more fully developed and future research elucidates specific processes, outcomes, and concerns related to telehealth strategies and practices. Documentation and Legal Considerations Although it has been stressed that the consultee remains clinically responsible for the patient who is the focus of the consultation, it is critical to appreciate that APRN consultants are accountable for their practices relative to the consultation problem. Once a consultantconsultee relationship has been established, scope of practice is implied and responsibility is assumed. This is initiated once the patient has been seen, recommendations have been rendered, and documentation has been entered into the patient chart. The duty of care and the legal responsibility to follow up on the consultation is of principal importance. The initial consultation should end with a summary communication to the consultee. This communication should ideally echo the documented recommendations but should be presented in person to the consultee or by telecommunication. Whether the consultee adopts the recommendations is entirely optional, according to professional skill and standard in the specialty. APRN consultation is influenced by factors such as professional standards of practice within the specialty, state and certification regulations, nurse practice acts, and institutional and group policies (Christensen, 2009). If malpractice were to be questioned involving consultation, it would be these specific documents and regulations that would be used to determine duty of care, standard of care, and/or damages, and with which type of provider the consultation is most appropriate. Inherent in the consultation process is the ability to communicate effectively, but little emphasis is placed on written communication through consultation notes. The art of writing a consultation note is learned primarily through trial and error or through mentorship with a senior practitioner (Stichler, 2002). Documentation is the best defense for the APRN consultant, whether the patient is seen or not. If the consultation is on the telephone, sidebar questions have been answered, or medical information interpreted about a patient, an event note should be entered into the chart. The EHR has become a convenient tool for documenting consultations and outcomes (McElwaine et al., 2014). Establishing a formal consultation relationship is protective to the APRN consultant and the consultee. The EHR has shifted legal trends to a more formal level. Legal action has been taken against APRNs and APRN consultants for informal consultation, and the establishment of a relationship between the consultant and patient should be delineated to avoid later legal risk due to lack of role clarity. The current trend for APRN consultation is more formal than informal. As the role of APRN consultant has expanded, it brings with it greater risk of professional liability in a litigious society. It is advisable that APRNs be aware of their malpractice coverage and, if employed in a high-risk area, be aware of the elements that constitute malpractice and plan for the management of risks involved. NPs often work with other health care professionals in collaborative settings. The laws governing the degree of supervision and protocol vary by state. These agreements address the level of physician oversight and consultation allowed independently by the APRN. In the most constructive settings, collaborative practice results in optimal patient care. Collaborative practice may create a lack of cooperation among physicians, NPs, health care entities, and pharmacies in the course of defending themselves against allegations of malpractice. These consultative situations raise complex issues in the event of a professional liability claim. In addition, evidence to substantiate claims regarding prescribing practices may be difficult to obtain. Because the APRN has the ability to examine, diagnose, and establish treatment plans for patients, friction may develop among the various health care professionals. Should these professionals become codefendants in professional liability litigation, an adversarial situation may result. In some jurisdictions, physicians may carry lower limits of professional liability coverage than an NP. In such cases, the NP may become the focus of the defendant's claim in an effort to collect from the NP's additional liability insurance coverage (Burroughs et al., 2007). Some APRNs prefer to purchase additional liability insurance. When obtaining insurance, the APRN consultant must consider the following: the practice setting, types of policies, components of the policy, costs, and the means to obtain adequate coverage (Scott & Beare, 1993). The best protection during a consultation includes good client communication and individualized client contracts. A wellwritten contract serves as a legal document to delineate responsibilities and outcomes, provide a professional image, and protect against possible negative developments. Discontinuing the Consultation Process There are circumstances in which an APRN has initiated the consultative process and recognition of safety or necessity warrants the closure of a consult. If the APRN has become aware that she or he or the patient is in a dangerous situation, and the consultee is not willing to intervene, the consultant would need to assume responsibility for ensuring safety needs and step out of the consultation role (Barron, 1983, 1989). Developing the Practice of Other Nurses Consultation from an APRN can enhance the clinical knowledge and practice of nurses requesting consultation. An outcome of APRN consultation, especially over time, is to encourage the professional development and practice of nurse consultees (Barron & White, 2009). One of the most rewarding aspects of the consultative process is to observe the growth in consultees and the mastering of new skills (Gray & Rutledge, 2014). The increasing number of DNPs in practice has significantly supported the confidence of engaging and effective consultation as a critical part of practice (Christensen, 2009). Christensen (2009) has emphasized the importance of selfevaluation following consultation. The approach and process of APRN consultation largely follows a medical model, focused on symptoms, at times excluding the fact that nurses possess the best traits of empathy, compassion, and holism. As consultants, APRNs are in a position to use the reflection skills they develop as graduate students and contribute to the consultation as a whole, being mindful of identifying the awareness of a therapeutic interpersonal relationship with patients. This process can enhance the learning of the consultee and the consultant, contributing in a meaningful way to the process (Barron & White, 2009). It is through critical reflection of the consultative process that nursing practice is advanced. The reflective nature of this element of advanced practice work promotes the development of future APRNs (Christensen, 2009). APRN Consultation and Research There is a decided gap around research evaluating the evidence-based impact of consultation on health care systems. In 2006 Yakimo wrote that there was a lack of outcome measurement, particularly in psychiatric consultation liaison nursing. In 2004, Yakimo, Kurlowicz, and Murray had systematically reviewed PCLN studies that looked at outcome in practice. They recommended that there be a mechanism for measuring change in patients or system using an established tool for measuring outcome. They stated that outcomes should be based on the particular interest/specialty group and that the measurement tool chosen should be specific enough to measure the intent of the intervention (Yakimo et al., 2004). While their study was applicable specifically to psychiatric consultation liaison nursing, it has merit for other subspecialties of APRN practice. Measuring outcome might involve using a tool but might also be viewed from a patient care perspective or improvement in functioning. The differences will involve who has requested the consultation, who the target group is for the intervention, and how the consultation is being used to improve patient care. The body of national and international research about the role of the APRN is growing. In each, consultation is cited as essential to the practice (Bryant-Lukosius et al., 2016; Fabrellas et al., 2015; Kutzleb et al., 2015; Perrin & Kazanowski, 2015). This reflects consultation as a core aspect of functioning in a broad picture of the APRN role as it is currently conceptualized. This is especially applicable in this era of shrinking resources, too few providers for the medical needs of the population, and a growing need for nursing expertise. Consultation, delivered in any manner, can expand the influence of the APRN and allow this expertise to reach a larger population of patients. Billing for Consultation Payment for consultation services is improving in some APRN roles, but APRNs need a clear understanding of the requirements for payment. Traditionally, the CNS, CNM, and certified registered nurse anesthetist were considered essential consultants and collaborators within the teams of specialty units. Yet these APRNs did not bill or were not reimbursed for their services (Buppert, 2012). In 2005 the Centers for Medicare and Medicaid Services decided that the shared visit rules for billing were not applicable to consultation (Buppert, 2012). Specifically, consultations cannot be billed “incident to.” There are specific Centers for Medicare and Medicaid Services criteria that must be met for APRNs to bill individually (Box 9.3). Box 9.3 Centers for Medicare and Medicaid Services Criteria to Bill for Consultation 1. Specifically, a consultation service is distinguished from other evaluation and management visits because it is provided by a physician or qualified nonphysician practitioner (advanced practice registered nurse [APRN]) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. 2. The qualified APRN may perform consultation services within the scope of practice and licensure requirements for APRNs in the state in which he or she practices. Applicable collaboration and general supervision rules (by state) apply, as well as billing rules. 3. A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for consultation services) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified APRN's plan of care in the patient's medical record. 4. After the consultation is provided, the consultant shall prepare a written report of her or his findings and recommendations, which shall be provided to the referring physician. There are five levels of current procedural terminology code for consultation. Adapted from Buppert, C. (2012). Update on consultation billing: Legal limits. Journal for Nurse Practitioners, 5, 730-732; and Burroughs, R., Dmytrow, B., & Lewis, H. (2007). Trends in nurse practitioner professional liability: An analysis of claims with risk management recommendations. Journal of Nursing Law, 11, 53-60. Consultations may be billed based on time if the counseling and coordination of care constitute more than 50% of the face-to-face encounter between the physician or qualified APRN and the patient. The preceding requirements (request, evaluation or counseling and coordination, and written report) shall also be met when the consultation is based on time for counseling and coordination (Buppert, 2012). When billing a consultation, the APRN must select the current procedural terminology code that is supported by documentation under Medicare's documentation guidelines. These guidelines can be found at www.cms.gov/. Also, Medicare administrative contractors have published their audit score sheets for evaluation/management on their websites. The most current information about billing is found on the website of the local contractor or agency billing representative. Evaluation of the Consultation Competency Ongoing evaluation of an APRN's skill in consultation is a requirement of the role. This involves overall evaluation of the consultative process and effective use of skills. APRNs should consider strategies that will assist them in determining their overall and specific effectiveness in relation to consultation. Data may be obtained from consultees, peers, administrators, review of the APRN's documentation of consultation, and the APRN's self-evaluation. Guidelines for consultation may vary by areas of specialty, which will dictate an individual APRN's practice. This variation in consultation practice also leads to variability in the appropriate questions and criteria used to evaluate the consultation skill. Examples of questions that may help with the evaluation of consultation skills include: • Are the consultant recommendations appropriate for the patient situation and do they result in improved patient outcomes? • Is the consultant contacted again after the initial consultation? • Are consultation requests for the APRN becoming more sophisticated over time? • Was the APRN able to respond to all requests for consultation? • Do glaring issues or needs seem to be going unaddressed? • Do there seem to be patterns in terms of the theme, number, or location of consultations? • Are there delays in doing consultation triage? The subjective experiences of the APRN consultant should be considered. Were the consultees open and comfortable with the consultant? Were consultees anxious or resistant? These data are subjective but important in evaluating the overall success of the consultation. Clinical competency, competency in applying the consultation process, interpersonal skills, and professionalism are all areas to be considered in evaluation. Identifying the individuals involved in the evaluation and developing a systematic approach to data collection regarding the consultation of the APRN practice are important and validate the need for the APRN consultant. Over time, assessment of change in the consultees or consultee system is the best evaluation of the competency. Obstacles to Successful Consultation Many obstacles can be identified for the APRN engaging in consultation. They include a lack of education about consultation models and the nuanced complexities of the process. Students are encouraged to read extensively about the process of consultation, the various types, and the ways nurse consultation can be implemented. Approaching a complex consultation without the knowledge of the system, the question being asked, or the aspects of the consultee that influence the process sets the consultant up to potentially fail in positively completing the consultation. Being set up by the broader system to fail with the consultation is a risk best avoided by knowledge and planning. When the consultation process is not about the consultation at all but about roles and expertise of the APRN, it can be indicative of larger problematic issues within the system. Students are encouraged to study the consultation process and to proceed thoughtfully when asked to provide a consultation. Knowledge and awareness of all the influencing factors provide the power that helps ensure successful consultation. Conclusion APRNs have a long tradition of involvement in various aspects of direct and indirect patient care activities, including consultation. APRNs use their consultation skills to improve care processes and patient outcomes. The power of consultative activities to inform and advance practice compels all APRNs to consider consultation as an integral aspect of role performance. Consultation offers APRNs the opportunity to both acquire and share the clinical expertise necessary to meet the increasingly challenging and diverse demands of patient care in a changing health care environment. APRN consultation contributes to positive patient outcomes and may promote more appropriate use of scarce health care resources. These assumptions require testing through quality improvement studies, cost-benefit studies, and research that examines the processes and outcomes of care. This procedure can result in effective measurement of consultation activities and resulting care outcomes. Consultation can facilitate having comprehensive and specialtyrelated knowledge directly and indirectly available to all patients who might need it and should be an expected and integral aspect of APRN role performance. In summary, this chapter has examined the art of consultation as it pertains to the APRN. As the sphere of nursing influence expands, APRNs are likely to have increased requests and demand for the consultation part of their specialty nursing practice. Key Summary Points ■ Consultation is an essential part of APRN practice regardless of role or specialty. ■ Consultation differs from co-management, referral, supervision, and collaboration. ■ Consultation, as described in this chapter, is an independent, autonomous nursing function, though APRNs must be aware of specific state regulations that impact APRN consultation activity. ■ It is important for the consultant and consultee to define expectations and responsibilities of the consultation, and there should be closed-loop communication to ensure successful closure of the consult. References American Association of Colleges of Nursing. The essentials of doctoral education for advanced nursing practice. [Retrieved from] www.aacn.nche.edu/publications/position/DNPEssentials.pdf; 2006. American Association of Colleges of Nursing. Essentials of master's education in nursing. [Retrieved from] www.aacn.nche.edu/educationresources/MastersEssentials11.pdf; 2011. 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Archives of Psychiatric Nursing. 2004;18:215–227. CHAPTER 10 Evidence-Based Practice Mikel Gray “Efficiency is doing the things right, effectiveness is doing the right things.” —Peter Drucker CHAPTER CONTENTS Evidence-Based Practice and the APRN, 226 Evidence-Based Practice, Research, and Quality Improvement, 231 Evidence and Current Best Evidence: Historical Perspective, 232 Steps of the Evidence-Based Process, 233 Step 1: Formulate a Measurable Clinical Question, 233 Step 2: Search the Literature for Relevant Studies, 235 Step 3: Critically Appraise and Extract Evidence, 240 Step 4: Implement Useful Findings in Clinical Decision Making, 248 From Policy to Practice: Tips for Achieving Meaningful Changes in Practice Based on Current Best Evidence, 250 Stakeholder Engagement, 252 Organizational Support, 252 Clinical Leadership Support, 253 Evidence-Based Practice Innovation: Feedback, 254 Future Perspectives, 254 Conclusion, 254 Key Summary Points, 255 Evidence-based practice (EBP) is the dominant approach for clinical decision making in the 21st century and a core competency of advanced practice registered nurse (APRN) practice (American Association of Colleges of Nursing [AACN], 2006, 2011). The primary purpose of this chapter is to review principles of EBP and how the APRN incorporates these principles into practice. It also describes the four steps of the evidence-based process and identifies resources that the APRN can use when making clinical decisions. EBP is defined as the conscientious, explicit, and judicious use of current best research-based evidence when making decisions about the care of individual patients (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Current best evidence is drawn from research produced by nurses or a variety of other members of the interprofessional team providing care to individual patients, groups of patients, or communities. Nursing research is defined as systematic inquiry that generates new knowledge about issues of importance to the nursing profession; individual studies may focus on clinical practice, education, administration, and informatics (Polit & Beck, 2016). Although all such research contributes to the nursing profession, current best evidence entails the application of research findings from studies that evaluate interventions or assessments used by nurses and other care providers to improve patient outcomes. For the APRN, much of this research will be generated by nurses. Nevertheless, the APRN will also draw upon research produced by multiple members of the interprofessional team who deliver modern health care and apply these findings to evidence-based clinical decision making as an individual provider or as a mentor or consultant to front-line nurses, physicians, and other care providers. Advanced practice nursing has evolved significantly since its inception in the 20th century. Entry into APRN practice now occurs following completion of a master's or doctoral degree. All APRNs are educated to seek out and apply current best evidence, which is the core component of EBP. In addition, the master's-prepared APRN may be involved with generation of original research, acting as a data collector or a member of a multisite clinical trial (AACN, 2011). The master's-prepared APRN also may participate in and lead quality improvement projects that collect and analyze data from a specific unit, facility, or multisite health system in order to evaluate and improve care processes in the unit, facility, or health system. The APRN who wishes to play a more active or lead role in generating original research may complete a doctoral program with a research focus. Most research-based doctoral programs in the United States lead to a Doctor of Philosophy (PhD) degree (AACN, 2011). These PhD programs prepare nurses for a research-intensive career; extensive coursework focuses on theory and metatheory, research methodology, and statistical analysis of findings needed to produce new knowledge for the advancement of nursing. Having completed a research doctorate, the PhD-prepared APRN may act as principal investigator or coinvestigator of studies with other nurse researchers. In addition, the PhD-prepared nurse may act as a member of an interprofessional team designing a research project, overseeing data collection, analyzing findings, and disseminating these findings via the professional literature. Many PhD-prepared nurses will function primarily in a faculty role, while others will engage in clinical practice based on their knowledge and training as an APRN. More recently, many APRN students are electing to complete a practice-focused doctorate degree, the Doctor of Nursing Practice (DNP). The DNP-prepared APRN is ideally prepared to synthesize existing research findings essential for EBP, to use data from increasingly sophisticated databases linked to Electronic Medical Record systems and national databases, and to participate in the formation of policies and procedures on a facility-wide or health system–wide basis. In addition, this individual may participate in the generation of original research as a data collector or clinical consultant to a research team charged with designing a particular study. The DNP-prepared APRN is also prepared to design and participate in quality improvement projects that analyze practice and processes within a specific facility or health system. Quality improvement projects are the evaluation of practice processes within a specific unit, clinic, facility, service, or community in order to change (improve) patient-centered outcomes, while a formal research study is designed to generate new knowledge. The DNP- prepared APRN also may synthesize findings from multiple studies via a systematic or scoping literature review resulting in ranking of levels of evidence, differentiate evidence-based from best practice–based assessments or interventions, and identify gaps in research. Whereas the role of the APRN in EBP is well established, the role of the master's- or DNP-prepared APRN in generating original research continues to evolve. Education programs provide essential knowledge and skills needed to enter into practice as a master's-prepared, DNPprepared, or PhD-prepared APRN. As DNP-prepared APRNs move into practice and gain greater expertise and knowledge through continuing education or individualized teaching from clinician or academic mentors, the individual's role in the generation of original research may evolve. Such evolution is especially likely for the first generation of DNP-prepared APRNs, who are just now entering practice in significant numbers. As these individuals move through their careers and gain expertise, they are likely to form strategic and productive alliances with PhD-prepared nurse researchers, physician researchers, and others who are likely to strengthen current best evidence and enhance current methodologic approaches via real-work clinical trials or use of metadata in order to more fully understand the processes of nursing and interprofessional clinical practice. The AACN (2015) has published a white paper concerning the role of the DNP in generation of new knowledge that provides initial expert opinion concerning this new level of APRN education and practice, but additional time is needed to determine the DNP's optimal involvement in the generation and synthesis of evidence. Evidence-Based Practice and the APRN EBP is the dominant approach for clinical decision making and a core competency for APRNs who hold a master's in nursing or a DNP (AANC, 2006, 2011; Stiffler & Cullen, 2010; see Chapter 3). The AACN has defined essentials of master's and doctoral education in nursing (AACN, 2006, 2011). All APRNs are expected to translate current best evidence into practice. The master's-prepared APRN is expected to integrate policies and seek evidence for every aspect of practice; this skill requires application of principles of EBP to clinical decision making and professional practice. Education within a DNP program builds on these skills by further developing the student's competencies to use analytic methods to appraise existing literature and other forms of evidence (such as abstracts or other forms of grey literaturea) into determining best practices; designing and implementing processes to evaluate practice outcomes; developing practice patterns that influence these outcomes; and comparing practice within an individual unit, facility, or health system against national benchmarks. The DNP-prepared APRN is also able to use information technologies in order to collect data related to current nursing practice patterns and outcomes, analyze these data, and play a leadership role in designing and implementing quality improvement initiatives and projects essential for application of current best evidence to the local unit, facility, or regional or national health system. Although components tend to overlap, three levels of this core competency for APRN practice can be identified: (1) interpretation and use of EBP principles in individual clinical decision making; (2) interpretation and use of EBP principles to determine policies, standards, and procedures for patient care; and (3) use of EBP to evaluate clinical practice. A formal, four-step process for identifying and determining EBP has been defined; it consists of: (1) formulation of a clinical question; (2) identification and retrieval of pertinent research findings based on literature review; (3) extraction and critical appraisal of data from pertinent studies; and (4) clinical decision making based on results of this process (Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000). This process was originally developed as a teaching strategy for medical students, and it remains the central process for creating current best evidence. Given the growing number of clinical practice guidelines and related EBP resources, this four-step process acts as a template for incorporating current best evidence in practice. Principles of EBP are used to guide clinical decision making for individual patients, for creating policies and procedures that influence current practice on a facility-wide or health system–wide level, and for determining policies for delivering care to large groups (Gerrish et al., 2011; Stiffler & Cullen, 2010). Despite widespread acceptance of the concept of EBP, adoption of current best evidence into daily practice remains limited. For example, analysis of mammogram use by the Behavioral Risk Factor Surveillance System found no significant change in rates of mammography screening among women less than 50 years of age despite a 2009 change advising against routine screening mammography in younger women (Dehkordy et al., 2015). Similarly, a random sample of 850 children from 28 schoolbased health centers in six states found that, despite recommendations from a multidisciplinary expert panel of physicians, nurses, nutritionists, psychologists, and epidemiologists, body mass index was not calculated on 27% of children's health records and blood pressure was not documented on 68.5% of records (Gance-Cleveland et al., 2015). Additional analysis revealed that slightly more than half of obese children (51.7%) were identified based on recommended screening procedures. A number of factors are thought to influence clinician acceptance and application of this problem-solving approach to direct patient care, including a lack of knowledge of the principles of EBP. This chapter defines EBP, differentiates it from concepts of research and quality improvement, and defines three levels of advanced practice nurse competency related to EBP (Table 10.1): TABLE 10.1 Overview of Evidence-Based Practice Competencies and Levels Competency Fundamental Expanded Level Level Level I: Incorporate Interpretation evidenceand use of based practice research and (EBP) other principles and evidence in processes into clinical individual decision clinical making practice. Create and incorporate EBP practices and principles on a unit, clinic, department, facility, health care system, national, or international level. The advanced practice registered nurse (APRN) may serve as member of interprofessional team formulating policies and procedures on a unit-wide, facilitywide, or health system–wide level. The APRN may function as member of an expert panel that formulates best practice, evidence-based, or blended practice guidelines intended for use on a national or global level. Level II: Use of EBP to change practice Incorporate best practice changes according to EBP principles into own practice or act as mentor to front-line staff incorporating change. Design and implement a process for changing practice beyond the scope of individual practice on a unit, clinic, facility, health care system, or national basis. Level III: Use of EBP to evaluate practice Identify benchmarks for evaluating own practice or participate in evaluation of practice among frontline nursing and other clinical staff. Design and implement a process to evaluate pertinent outcomes of practice beyond the scope of individual practice (e.g., generic nursing practice, group APRN practice, interprofessional team practice, facility-wide or health care system–wide practice). Level I: use of evidence in individual APRN practice Level II: use of evidence to change practice Level III: use of evidence to evaluate practice Exemplars 10.1, 10.2, and 10.3 provide examples of each of these EBP-related competencies. Exemplar 10.1 Level I: Interpretation and Use of EvidenceBased Practice in Individual Clinical Decision Making The most basic level of evidence-based practice (EBP) competency is the application of the four steps for clinical decision making in an individual patient. This proficiency requires more than formulation of a clinical question and identification of pertinent studies needed to determine best available evidence. The advanced practice registered nurse (APRN) must combine knowledge of best evidence with an assessment of individual patient factors likely to affect treatment effects, such as the presence of comorbid conditions, psychosocial and cultural factors such as locus of control, preference and impact on quality of life, and cost considerations. Example: As an APRN in a urology department, I am often asked by patients and physician colleagues whether cranberry juice or supplements (including cranberry capsules) should be prescribed to prevent urinary tract infection (UTI). This persistent query led me to formulate a clinical question, “Are cranberry juice or cranberry products effective in the prevention or management of urinary tract infection?” A systematic literature review based on current best evidence available in 2002 suggested that regular consumption of cranberry juice reduces the incidence of UTIs in communitydwelling women and residents of long-term facilities but does not reduce the risk in patients who undergo intermittent or indwelling catheterization (M. Gray, 2002). The findings of this systematic review were further supported by a recent randomized controlled trial (RCT) that evaluated a 6-week course of cranberry juice versus placebo capsules in 106 women following gynecologic surgery. Analysis revealed a lower incidence of UTI in women allocated to active cranberry tablets; this difference persisted after adjusting for likely confounding variables, including intermittent selfcatheterization (Foxman, Cronenwett, Spino, Berger, & Morgan, 2015). However, additional evidence has emerged that influences these conclusions. Specifically, two RCTs published in 2011 and 2012 found that cranberry juice was no more effective than antimicrobial therapy or cranberry-flavored placebo drink for preventing UTI (Barbosa-Cesnik et al., 2011; Stapleton et al., 2012). On initial consideration, this evidence appeared to support discontinuing recommendations of consumption of cranberry for women seeking to prevent recurrent UTIs. However, additional evaluation of findings from one of the studies, a study using a placebo group (Barbosa-Cesnik et al., 2011), revealed that both groups experienced a considerably lower incidence of UTIs than anticipated. In a subsequent interview with one of the investigators, the researchers acknowledged a possibility that the placebo-flavored drink might have contained some of the ingredients hypothesized to exert an antimicrobial effect in the urine (Larson, 2010). In addition, I considered the fact that consumption of cranberry juice twice daily is not associated with any known harmful side effects. I also considered the fact that cranberry juice is relatively inexpensive compared with dietary supplement cranberry capsules. As a consequence of all these factors, cranberry juice is preferred as a natural means for preventing UTIs among many women in my practice. This example of basing individual clinical decisions on an EBP process illustrates several important points. It points out the importance of remaining abreast of emerging evidence and the real possibility that newer evidence may significantly alter our understanding of the benefits or harmful effects associated with a specific intervention. In addition, this case illustrates the role of patient preference in clinical decision making. Clinical experience strongly suggests that a significant proportion of women prefer nonpharmacologic interventions for preventing UTIs, and regular consumption of cranberry juice tends to increase overall fluid intake and provide possibly beneficial effects without associated adverse side effects. Therefore, given the absence of harm, low direct cost, and mixed evidence concerning efficacy of this preventive intervention, I discuss consumption of cranberry juice with women as a possibly effective intervention that is free from harmful side effects. I also counsel women to consider engaging in other behavioral interventions for the prevention of UTIs, including adequate daily fluid intake based on recent recommendations from the Institute of Medicine, daily consumption of a dietary source of the probiotic lactobacillus, and consideration of avoiding use of a diaphragm and vaginal spermicide as birth control strategies (Salvatore et al., 2011). This case also illustrates the time-consuming and rigorous demands of basing individual clinical decisions on the EBP process. Fortunately, APRNs have access to various evidence-based resources such as the Cochrane Database of Systematic Reviews and the systematic reviews available at the U.S. Preventive Services Task Force web page. In addition to these resources, a growing number of professional societies have generated evidence-based clinical practice guidelines that address measurable clinical questions with thorough and extensive systematic reviews of existing evidence to formulate clinical recommendations covering comparatively broad topics such as heart failure, diabetes mellitus, chronic obstructive pulmonary disease, breast cancer, end-stage renal disease, osteoporosis, and other topics of special interest to APRN practice. In addition to searching the resources of the appropriate professional association's web page, the National Clearinghouse of Practice Guidelines, operated by the Agency for Healthcare Research and Quality, houses a large collection of evidence-based clinical practice guidelines that can be accessed at http://www.guideline.gov. Exemplar 10.2 Level II: Interpretation and Use of EvidenceBased Practice to Create Policies for Patient Care For many advanced practice registered nurses, the growing demand to formulate evidence-based policies and protocols needed to prevent the growing list of “never events” provides an opportunity to master the second competency level, interpretation and use of evidence-based practice (EBP) to create policies for patient care. Example: Fineout-Overholt, Melnyk, Stillwell, and Williamson (2010a, 2010b, 2010c) have described the EBP process needed to answer a clinical question about whether a rapid response team affects the number of cardiac arrests and unplanned intensive care unit admissions in hospitalized adults. Based on this question, the authors described the process used to search the evidence for pertinent studies, code and extract data from these studies using a standardized protocol, and synthesize data to implement policies needed to launch a rapid response team at their facility. Based on this process, the team concluded that there is sufficient evidence to justify developing policies and committing the resources needed to form a rapid response team at their facility. In addition to providing an example of the EBP described in this chapter, this series of articles describes the processes required to implement such a program. Although a detailed discussion of this translation from research-based evidence to clinical practice is beyond the scope of this chapter, the authors identified and briefly reviewed essential components of this step in the implementation process, including engaging stakeholders in their facility; securing administrative support; preparing a campaign to launch the rapid response team, including staff education and changes in care protocols; and measuring outcomes following implementation of the practice change. Exemplar 10.3 Level III: Evaluation of Evidence-Based Practice to Determine Standards of Care Participation in an interprofessional team to evaluate and determine standards of care using evidence-based practice (EBP) is the third and most advanced level of the EBP competency for advanced practice registered nurse (APRN) practice. Generation of an evidence-based clinical practice guideline entails identification of a number of clinically measurable questions required for establishing and evaluating clinical practice in a broad area of patient care, along with an extensive systematic review of pertinent studies. This often encompasses major assessment strategies related to the management of a particular disorder and first-line and alternative interventions for management. Example: A professional nursing society charged a task force of three APRNs with clinical expertise in chronic wound care with development and validation of an evidence-based algorithm for use of compression for prevention and treatment of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) (Ratliff, Yates, McNichol, Gray, 2016). The task force began this task by identifying pertinent clinical questions, an appropriate theoretical framework for clinical decision making in patients with CVI and/or VLUs, and an exploratory literature review. The nursing society committee selected a PhD-prepared APRN with experience in literature review and generation of evidence-based guidelines for clinical practice, including algorithms. Patient population/Problem, Intervention, Comparison, and Outcome (PICO)–formatted questions were generated by the three-member task force and a literature review was initiated. It soon became apparent that the algorithm must combine evidence-based decisional nodes with clinical decision points that lack sufficient evidence to be deemed evidence based. Based on this initial review, the task force elected to complete a scoping review that focused on current clinical practice guidelines and research specifically focusing on a single aspect of CVI and VLU prevention and treatment: compression. This search revealed eight clinical practice guidelines; each recommended compression as part of a bundle of interventions for prevention and management of CVI and VLUs, but none provided adequate guidance concerning when to select a specific type of compression (stockings, bandages, intermittent pneumatic compression devices) or best practices for donning and removing compression devices. Based on these initial findings, a second phase of the literature review was completed that included studies in adult patients that compared one or more types of compression, or evaluated techniques for aiding patients or lay caregivers in donning or removing compression devices. This two-step scoping literature review was used to develop a draft algorithm that incorporated evidence-based interventions and interventions lacking adequate clinical evidence, along with evidence-based statements supporting the algorithm and best practice statements linked to clinical decisions not supported by adequate research-based evidence. A multidisciplinary team that represented all regions of the United States was assembled that reviewed and critiqued the algorithm and reached consensus on best practice statements supporting the algorithm. This panel comprised APRNs, specialty practice nurses in wound, ostomy and continence vascular care, physical therapists, physicians, and basic science researchers in the area of compression devices. Under the direction of this multidisciplinary group, the algorithm was modified, including addition of supplemental materials deemed necessary for adaptation of the algorithm by clinicians with limited experience and knowledge in management of CVI and VLUs. It was also adapted into an electronic format for ease of use in multiple care settings. This second draft of the algorithm was submitted to content validation by a second and separate multidisciplinary group that was composed of APRNs, specialty practice nurses, physicians, and physical therapists. The resulting guideline has been downloaded by more than 7000 providers in North America, including APRNs, specialty practice nurses, vascular surgeons, and physicians and physical therapists specializing in chronic wound care. The construction and validation of this algorithm demonstrates how a small task force of APRNs consulted with a PhD-prepared APRN to design PICO-based questions and complete a scoping literature review that combined evidence-based decisions with best practice decisions essential to construction of a clinically relevant and pragmatic algorithm guiding APRNs, specialty practice and front-line nurses, physicians, and physical therapists in selecting, applying, and reapplying compression for prevention and management of VLUs in adult patients with CVI. Research concerning the influence of this algorithm in two settings, long-term care and home care, is ongoing. The term evidence-based practice represents a blending of several related concepts, including evidence-based nursing and evidencebased medicine. The original term, evidence-based medicine, traces its historical roots to a strategy for educating medical students developed by the faculty at McMaster Medical School in Hamilton, Ontario (Rosenberg & Donald, 1995). Evidence-based nursing is defined as the process that nurses use to make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences (DiCenso, Cullum, & Ciliska, 2002). The explicit inclusion of patient preference and clinical expertise is significant for APRNs because they reflect the holistic approach central to nursing practice while maintaining the focus on current, research-based evidence. EBP offers several advantages when compared with previous models of clinical decision-making. For example, tradition-based practice is based on clinical and anecdotal experience, combined with received wisdom, often provided by instructors or clinical preceptors and expert opinion from those perceived as experts or expert clinicians in a given area of care. By substituting a standard of current best evidence for received wisdom or expert opinion, EBP encourages the advanced practice nurse to update and refine clinical practice continually as newer evidence is generated and published. EBP also offers distinctive advantages when compared with rationale-based clinical decision making. Rationale-based clinical decision making relies on identifying a rational explanation for an intervention (Gray et al., 2002). This form of clinical decision making relies on findings from a wide variety of studies, including pathophysiologic research designed to identify the principal action of an intervention or the main reason it exerts a particular effect, and in vitro or in vivo research models that measure outcomes in animals, tissues, or individual cell lines. Although these types of studies are enormously valuable to our overall understanding of health, disease, and the reasons that interventions exert a particular effect, EBP limits its search for evidence to studies that directly measure the efficacy or effectiveness of a particular intervention, the predictive power of diagnostic studies, and the presence and severity of adverse side effects. Evidence-Based Practice, Research, and Quality Improvement The process and outcome of EBP should be differentiated from the process of generating a research study or completing a quality improvement (QI) project (Shirey et al., 2011; Table 10.2). Research is a systematic investigation designed to generate or contribute generalizable new knowledge to health care or advanced practice nursing (Arndt & Netsch, 2012). In contrast, EBP combines findings from multiple research studies that focus on the efficacy of a particular intervention or the accuracy of a specific diagnostic procedure. EBP has been described as the study of studies; its goal is the synthesis of existing knowledge generated from multiple research studies, whereas the goal of an individual research study is to generate new knowledge about an intervention or assessment technique (Gray et al., 2002). QI is defined as a systematic activity that generates outcome data in order to achieve rapid improvements in health care delivery in a specific setting (Arndt & Netsch, 2012; US Department of Health and Human Services, Health Resources and Services Administration, 2011). The data generated during a QI project is designed to improve specific outcomes within a local facility, clinic, or community. Unlike the data generated by a research study, the results of a QI project can only be generalized to the specific patient population that comprised the project setting. TABLE 10.2 Despite these differences, the APRN should remember that research, EPB, and QI projects share a common goal—improvement of patient care. Further, research, EBP, and QI should be viewed as complementary and combined in a manner that improves individual clinical decision making and care processes affecting an entire facility, health care system, or larger community. For example, an acute care APRN may observe that the ventilator-associated pneumonia (VAP) incidence in his or her facility's critical care unit is higher than published benchmarks. As a result, the APRN elects to complete a QI project designed at reducing the incidence of VAP. Initially, the APRN should review the unit's current prevention protocol to determine whether it is based on current best evidence, such as routine oral hygiene, regular evaluation for readiness to extubate, elevation of the head of the bed, and prophylaxis for peptic ulcer disease and deep vein thrombosis (Eom et al., 2014). This review may incorporate principles of EBP and findings from individual research studies to answer two questions: • Are the preventive interventions used by local staff based on current best evidence? • Does existing research suggest that combining these interventions into a prevention bundle actually reduces the incidence of VAP? In reference to the first question, a review of current best evidence suggests that bundled interventions are effective for reducing the incidence of VAP (Eom et al., 2014; Ramirez, Bassi, & Torres, 2012). When examining individual interventions, the acute care APRN may note that current best evidence supports regular oral hygiene that incorporates chlorhexidine as effective for preventing VAP (Vilela, Ferreira, Santos, & Rezende, 2015). In contrast, limited evidence suggests that ongoing elevation of the head of the bed may not affect VAP incidence, even though it is associated with an increased likelihood of sacral pressure ulcer formation (Edsberg, Langemo, Baherastani, Posthauer, & Goldberg, 2014; Leng, Song, Yao, & Zhu, 2012;). Finally, the APRN also may identify findings from an individual study, the NASCENT randomized clinical trial. This study demonstrated that a silver-coated endotracheal tube reduced the incidence of VAP (Kollef et al., 2008) in 9417 critically ill adults from 54 facilities in North America. Thus the APRN has synthesized essential research-based knowledge using principles of EBP to provide a platform for a QI project. Depending on existing policies in the local critical care unit, the APRN may collaborate with others to create a modified or novel prevention bundle and measure VAP incidence before and following implementation of this bundle. Findings of this process comprise a QI project; although these results cannot be generalized to every critical care unit, they can be used to evaluate care processes in the local critical care unit. Evidence and Current Best Evidence: Historical Perspective Although the concept of “best evidence” may appear transparent on initial consideration, a more careful analysis of the historical roots of evidence generation in health care is needed. The Oxford English Dictionary Online (2016) defines evidence as an object or document that serves as proof. The objects or documents acceptable for use as evidence vary for each discipline or profession; historians seek out original documents or artifacts, and lawyers have developed a complex system for identifying evidence codified with federal, state, or other rules of evidence documents. Within the context of EBP, clinicians seek studies to establish evidence for the efficacy and safety of an intervention, or the predictive power of a diagnostic procedure. Although the search for evidence can be traced back more than 2000 years, definitions for what constitutes sufficient evidence to reach these conclusions have evolved significantly over time. Despite a growing number of study designs used to evaluate the effectiveness of various interventions, diagnostic procedures, and intervention bundles, the randomized controlled trial (RCT) remains the gold standard research design for generating evidence (Sackett, 2015; Turner, 2012). The RCT is based on three critical elements: (1) manipulation of an experimental intervention; (2) comparison of the group receiving the experimental intervention to a control or comparison group that receives a placebo, sham device, or standard intervention, depending on ethical considerations; and (3) random allocation of subjects to the intervention or comparison/control group. Random allocation, advocated since the early 1930s, is an essential element of an RCT because it is the most effective technique for spreading potentially confounding factors evenly among treatment and control groups (Hill, 1937). A well-known RCT that compared streptomycin with standard care at the time (bed rest) is usually cited as the world's first, large-scale, controlled trial (Streptomycin treatment, 1948). Randomization was achieved using a closed envelope system and subjects were blinded to treatment group. However, at least one trial was completed and published before this landmark study. Amberson, McMahon, and Pinner (1931) compared the antibiotic sanocrysin for treatment of pulmonary tuberculosis with a placebo. In addition to random allocation of subjects by flipping a coin, they also blinded physician data collectors to group assignment to minimize bias, another important design feature of the modern RCT. Based on this historical legacy and guided by the pioneering efforts of Archibald Cochrane, current best evidence is now defined as the best available studies evaluating the efficacy and safety of an active or preventive intervention or the predictive accuracy of an assessment (Gray et al., 2004; van Rijswijk & Gray, 2012). These studies must directly evaluate the effect of an intervention; compare the intervention with a placebo, standard care, or a sham device; and document adverse side effects associated with the intervention. Studies used to establish current best evidence must be executed in human (rather than animal) subjects and must measure the most direct outcome of treatment, rather than relying on interim outcomes based on convenience. For example, a study of the efficacy of a topical wound therapy should measure wound closure rather than concluding efficacy based on the percentage of wound closure completed at a convenient or arbitrary point after the initiation of treatment (van Rijswijk & Gray, 2012). This definition of current best evidence raises a corollary question: What criteria must be fulfilled to define an intervention as “evidencebased?” At least two major regulatory groups, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA), have established specific criteria for labeling an intervention as evidence based (Cormier, 2011). For a drug to receive an indication for clinical use, the FDA requires results from two well-designed RCTs with consistent results, both of which must compare the agent with a placebo- or sham-based control group; the EMA criteria are similar (EMA, 2000). Although these groups provide well-defined criteria for defining an intervention (administration of a drug) as evidence based, achieving this level of evidence is complex and enormously costly. For example, the total cost of achieving a new drug indication has risen sharply over the past decade and may be as high as $2.5 billion (Mullin, 2014). Based on these rigid criteria, only a minority of interventions that APRNs use to manage their patients would qualify as evidence based, and limited research in this area has suggested that 40% of clinical decisions used in daily practice are unsupported by evidence (G. E. Gray, 2002; Greenhalgh, 2001). As a result, APRNs often must search the literature and identify relevant evidence to support clinical decision making in a particular case or group of patients, or retrieve this information from EBP resources, such as clinical practice guidelines or best practice documents. Steps of the Evidence-Based Process Step 1: Formulate a Measurable Clinical Question Clinical decision making using the EBP process begins with the formulation of a measurable clinical question. Questions arise from various sources. For example, many APRNs will formulate their first clinical questions as part of an EBP process when planning their final scholarly project as part of a DNP degree. Individual clinical APRN or staff nurse practice provides another rich source for clinical questions. Queries may arise when the APRN is faced with a questionably effective intervention or when managing an uncommon or rare disorder that is not addressed in major clinical practice guidelines. APRNs often serve on multidisciplinary committees that may be charged with developing a policy or protocol for presenting or managing a particular clinical challenge. For example, the growing list of “never events” (National Quality Forum, 2016) presents an ongoing challenge to APRNs practicing in the acute and critical care settings, who are often charged with designing facility-wide prevention programs for conditions such as catheter-associated urinary tract infections, surgical site infections, and central line–associated bloodstream infections. After identifying the general topic to be scrutinized, the APRN must formulate a measurable question that can be meaningfully addressed using evidence-based clinical decision strategies. Results of several studies have suggested that application of the PICO model aids nurses in formulating clinically relevant and measurable questions as well as assisting in efficiently searching the literature for available evidence (Balakas & Sparks, 2010; Hastings & Fisher, 2014; LaRue, Draus, & Klem, 2009; Smith-Strøm & Nortvedt, 2008; Table 10.3). TABLE 10.3 PICO(T) Model for Generating EBP Clinical Questions Component Definition P Patient/Population—identify the population of interest Problem—identify the primary problem I Intervention—identify the intervention(s) to be considered C Comparison—identify to what the intervention will be compared O Outcome—identify the goal of the intervention(s) T* Time—time frame for measuring outcomes * Optional. Adapted from Smith-Strøm, H., & Nortvedt, M. W. (2008). Evaluation of evidence-based methods used to teach nursing students to critically appraise evidence. Journal of Nursing Education, 47, 372–375; and Sackett, D. L., Strauss, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). London: Churchill-Livingstone. The P in PICO indicates patient or population (Hastings & Fisher, 2014), although the P is sometimes expanded to include the primary problem (Balakas & Sparks, 2010). This element of the formula alerts the APRN to define the population to be studied and the nature of the problem to be scrutinized carefully. The population may comprise a subgroup of patients in a facility, such as critically ill patients receiving mechanical ventilation or all patients with an indwelling urinary catheter, but it often incorporates much larger populations, such as any individual with a wound or any patient recently diagnosed with diabetes mellitus. As these examples illustrate, identification of the primary problem is closely tied to the population under scrutiny. Examples of primary problems may be a disease such as sinusitis, a disorder such as chronic osteoarthritis, or a predisposition to a potentially preventable condition such as a pressure ulcer. The I in the PICO model represents the main intervention to be considered. In many cases, an APRN will examine a single intervention such as using a follow-up telephone intervention for reducing fasting blood glucose levels in patients with diabetes mellitus (Evans, 2010). In contrast, the combined effect of more than one intervention used to prevent or treat a specific disorder can be evaluated. For example, the APRN can identify a protocol or bundle of interventions and analyze their effect on a given outcome. Searching for evidence that evaluates the combined effect of multiple interventions is clinically useful, but it presents unique challenges. For example, Hagiwara, Henricson, Jonsson, and Suserud (2011) studied whether decision support tools decrease the time to receive definitive care in acutely ill or trauma patients prior to hospital admission. They operationally defined “decision support tools” as active knowledge systems that use two or more items to generate case-specific advice. They further classified these tools as electronic or nonelectronic. However, their literature search retrieved only 2 of 33 studies that specifically addressed this clinically relevant question. Despite the use of a well-accepted definition for decision support tools, the authors observed that a number of studies were excluded because it was not possible to classify the study intervention as a decision support tool. Nayan, Gupta, and Sommer (2011) faced a similar challenge when studying whether smoking cessation rates were higher in oncology patients who receive smoking cessation interventions as compared with usual care. Their initial search identified a meta-analysis of data from eight RCTs that detected no differences in self-reported cessation rates when these interventions were compared with usual care. However, subclassifying smoking interventions into pharmacologic, behavioral, and combined interventions suggested that cessation protocols that combine pharmacologic and behavioral interventions appeared to increase cessation rates when compared with usual care or single-intervention protocols. The C in the PICO model represents the approach used as a basis for comparison to the intervention undergoing scrutiny. This approach is frequently described in research reports as standard care or usual care. Although these terms are descriptive, it is essential that the APRN specifically define the intervention(s) that comprise standard care and ensure that the studies retrieved enable adequate differentiation of this standard care from the intervention under scrutiny, especially when evaluating the effect of a bundled intervention or protocol. The O in PICO represents the outcome, or intended goal of the intervention. When determining the outcome, it is important to identify and evaluate the most direct result indicating clinical efficacy and avoid reliance on indirect outcomes that are more easily measured. Careful consideration of the most direct and clinically relevant outcome is essential when constructing a clinically relevant question. For prevention studies, the most direct outcome is generally a reduction in the incidence of the disease or disorder under scrutiny. For example, an APRN evaluating the effect of a prevention protocol on surgical site infection rates should base conclusions of efficacy on incidence rates, rather than on interim outcomes such as differences in a nurse's knowledge after education on prevention or self-reported changes in practice following in-service training. The APRN should also measure process outcomes that may influence whether the intended goal or outcome is met. A final element, T, indicating time, may be added to the PICO conceptual framework. The time frame is meant to indicate the relevant observation period for outcomes; it may be short, such as the first 24 to 48 hours following surgery, or long, such as years to decades following the onset of a chronic condition such as dementia or diabetes mellitus (Balakas & Sparks, 2010; Hastings & Fisher, 2014; Milnes, Gonzalez, & Amos, 2015). Step 2: Search the Literature for Relevant Studies Evidence-based clinical decision making relies on identifying research-based evidence. Therefore, it is essential for the APRN to develop expertise in searching the literature to identify and retrieve appropriate studies. Fortunately, the development of modern electronic databases has revolutionized our ability to search the published literature rapidly and access pertinent research reports. A number of electronic databases are now available to the APRN (Table 10.4). Although full access to these databases usually requires a paid subscription, APRNs may access these electronic databases via a facility-based subscription. Specifically, the vast majority of health system, university, or college libraries maintain institutional subscriptions to Ovid, ensuring access to multiple electronic databases such as MEDLINE or CINAHL. In addition, access to PubMed, a service of the MEDLINE database, is available without charge on the Internet. TABLE 10.4 Examples of Electronic Databases for Identifying and Retrieving Pertinent Research Name Description URL MEDLINE Largest online database for nursing, medical, and allied health journals https://www.nlm.nih.gov/bsd/pmresources.html PubMed Freely accessible online version http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed of MEDLINE database; lacks the robust Boolean features of MEDLINE Cumulative Index to Nursing and Allied Health Literature (CINAHL) Largest database for nursing and allied health literature; includes multiple nursing journals not indexed in the MEDLINE database http://www.ebscohost.com/biomedical-libraries/the-cinahl-database Education Linked to more http://www.eric.ed.gov/ Resource than 320,000 Information articles from Center 1966 to the (ERIC) present; focuses on educational literature, including undergraduate and graduate nursing PsycINFO Contains more than 3 million resources dating back to 1888; excellent resource for the APRN who specializes in providing mental health care http://www.apa.org/pubs/databases/psycinfo/index.aspx Web of Science Includes journals in the basic and clinical sciences https://apps.webofknowledge.com/WOS_GeneralSearch_input.do? product=WOS&search_mode=GeneralSearch&SID=1AtDcGoWCHV3rnpT4ub&pre drawn from approximately 9300 journals with impact factors; administered by Clarivate Analytics MEDLINE and PubMed Administered by the US National Library of Medicine, MEDLINE is the world's largest electronic database of health-related research and literature (US National Library of Medicine, 2016). There are articles from a number of professions, including medicine, nursing, dentistry, veterinary medicine, and associated disciplines such as physiology, pharmacology, and molecular biology. Approximately 5600 journals are indexed. The MEDLINE database is primarily organized around MESH (medical subject headings) terms. Entering a MESH term, such as “coronary artery disease” or “osteoporosis,” will trigger a number of subheads that are potentially useful to identify evidence for answering a clinical question, such as “diagnosis,” “drug therapy,” “diet therapy,” and “nursing.” The MEDLINE database may also be searched using various keywords that are not official MESH terms; these searches retrieve articles that include the keyword in its title, abstract, or in a list of identifying keywords, but they will not provide the subheads available when a MESH term is accessed. The MEDLINE database includes articles published in 39 languages; 91% are printed in English and 83% of those published in other languages have English language abstracts, greatly increasing access for Englishspeaking searchers. MEDLINE has robust Boolean functions, allowing the APRN to focus or narrow a search by combining two or more MESH terms or keywords using the functions “AND,” “OR,” and “NOT” (U.S. National Library of Medicine, 2016). For example, an APRN might pose a question about the effectiveness of administering an angiotensin-converting enzyme inhibitor for the prevention of mortality and disease progression in patients with heart failure. In this case the APRN might initially select the MESH term “heart failure” along with the MESH term “angiotensin-converting enzyme inhibitors.” By using the “AND” Boolean function, the database will retrieve articles that merge the intervention (angiotensin-converting enzyme inhibitor agents) with the primary patient problem under scrutiny (heart failure). A second Boolean function, “OR,” allows the searcher to retrieve articles that contain either of two keywords or MESH terms. This function is useful when terms that are recently coined or historically relevant differ from the corresponding MESH term. For example, an APRN may be seeking information about patients who experience chronic lower urinary tract pain not associated with bacterial infection. The MESH term for this condition is “interstitial cystitis.” However, a more recent term (bladder pain syndrome) has been increasingly used to describe this condition (Hanno et al., 2014); combining the MESH term “interstitial cystitis” with the keyword “bladder pain syndrome” retrieves more citations that entering either term alone. A third Boolean function, “NOT,” allows the APRN to limit a search by eliminating articles that do not address the intervention, assessment, or patient population under scrutiny. For example, an APRN interested in prevention of central line infections might enter the MESH term “indwelling catheters,” which will retrieve studies focusing on infections associated with multiple types of catheters, including urinary and peritoneal dialysis catheters. Use of the “NOT” Boolean function will enable the APRN to eliminate articles about various types of catheters not pertinent to a clinical question focusing on hospital-acquired central line infections. The MEDLINE database allows searches via multiple alternative fields, including author, journal, publication type (e.g., review article), language, experimental approach (human, in vivo, or in vitro), gender, age range, and publication year. These options are useful for focusing searches based on the parameters specified in the clinical question. The PubMed webpage (http://www.ncbi.nlm.nih.gov/pubmed) provides free access to the MEDLINE database. The basic search engine will retrieve articles based on keywords. Clinicians searching PubMed can click on an advanced search icon and access a site that allows a combination of keywords or keyword and author or journal using the Boolean function “AND.” However, the PubMed database does not have the robust search functions characteristic of MEDLINE. In addition, although a limited number of articles can be downloaded directly from the PubMed site, access to most articles is restricted to the complete citation and abstract. Cumulative Index for Nursing and Allied Health Literature The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is an electronic database containing more than 2.6 million elements from approximately 3000 nursing and allied health journals and books. Similar to MEDLINE, the CINAHL database is available online as a subscription service typically accessed as part of an EBSCO Information Services subscription maintained by larger health care facilities and universities. Articles can be searched using keywords; the CINAHL database also contains the Boolean features “AND,” “OR,” and “NOT” and multiple search fields similar to those described for MEDLINE. CINAHL also indexes doctoral dissertations, an important source for gray literature (unpublished documents) in the field of nursing. Online Evidence-Based Resources In addition to retrieving individual research reports from electronic databases such as MEDLINE and CINAHL, the APRN should also search online evidence-based documents such as the Cochrane Library and PubMed Health. The Cochrane Library is part of the Cochrane Collaboration; it is administered by a nonprofit organization, and reviews are generated by more than 28,000 volunteers from across the globe (Cochrane Collaboration, 2016). The Cochrane Library contains multiple resources for identifying current best evidence, including the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. The Database of Systematic Reviews contains more than 5000 systematic literature reviews based on clinical questions covering almost every specialty practice area in contemporary health care. Whenever possible, these reviews include a meta-analysis of data pooled from comparable studies. The systematic reviews can be accessed by multiple search fields, including keywords found in the title or abstract and author. Systematic reviews can be retrieved as a summary, standard report, or full report. A plain language summary provides a brief synopsis of the review's main findings. A standard report provides more detailed information, including a structured abstract of the review, plain language summary, background, objectives, methods, results, and discussion, along with reference lists for included and excluded studies. Systematic reviews are also available as a full report that incorporates all the elements of the standard report plus a detailed summary of all analyses generated for the review. The plain language summary is useful as a quick reference when the APRN is only interested in a succinct summary of the main findings of a systematic review; this document may also be shared with a patient or family with a college-level education who may wish to know more about evidence supporting a particular intervention or assessment strategy. The full summary provides the more detailed information necessary when the APRN is evaluating current best evidence for individual decision making or generation of recommendations for practice. The detailed report also may be used for this purpose; study of this longer version is especially recommended for the novice APRN who is learning to synthesize evidence for clinical decision making or generating evidence-based documents such as a plan for a scholarly project. Other online resources include the Joanna Briggs Institute, Essential Evidence Plus, and PubMed Health. The Joanna Briggs Institute is an international collaboration of nurses and other allied health care professionals, including the Cochrane Nursing Care Field and Cochrane Qualitative Research Methods Group, that provides evidence-based resources for nursing (Joanna Briggs Institute, 2016). Essential Evidence Plus is a subscription service administered by Wiley-Blackwell Publishers (Essential Evidence Plus, 2016) that enables users to access multiple electronic databases, including the Cochrane Library, to obtain evidence-based resources and information. An individual or institutional subscription to Essential Evidence Plus also provides access to POEMS (Patient-Oriented Evidence that Matters). POEMS are regularly updated synopses of evidence from individual studies and an archive of more than 3000 previously posted summaries. They may be downloaded online, downloaded to a smartphone, or viewed via podcast. PubMed Health is an electronic database for evidence-based resources administered by the National Center for Biotechnology Information, US National Library of Medicine (http://www.ncbi.nlm.nih.gov/pubmedhealth). This electronic database includes reviews of clinical effectiveness research; reviews are available in brief reports designed for use by consumers, along with full reports designed for use by clinicians such as APRNs. In addition to its link to the extensive MEDLINE/PubMed database, PubMed Health is linked to evidence-based resources from the Cochrane Library, the Agency for Healthcare Research and Quality (AHRQ), the National Cancer Institute, the National Institute for Health and Clinical Excellence (NICE) guidelines program, and the National Institute for Health Research, Health Technology Assessment Program. Table 10.5 summarizes additional online resources for EBP. TABLE 10.5 Clinical Practice Guidelines Searches of electronic databases should also incorporate the identification and retrieval of existing clinical practice guidelines or best practice documents. Clinical practice guidelines may be enormously helpful to the APRN because they represent a systematic review of existing evidence based on measurable clinical questions and recommendations for management of the disease, disorder, or condition (Fletcher, 2008). Identification and incorporation of appropriate guidelines is also important to APRNs because these documents are increasingly being viewed as a standard of care among clinicians, especially given the widespread acceptance of EBP principles. In addition to increasing scrutiny by clinicians, courts within the United States have also begun to grapple with the issue of clinical practice guidelines and their relationship to the legal definition of a standard of care. The current legal definition for standard of care for physicians is “that which a minimally competent physician in the same field would do under similar circumstances” (Moffett & Moore, 2011, p. 111). Legal precedents concerning use of these documents continues to evolve; nevertheless, multiple courts have ruled that guidelines may be used as learned treatises to lend credence to or impeach an expert witness, to defend a clinician for using recommendations with the document as a standard of care, and to suggest that the clinician failed to deliver standard of care by not following guideline recommendations (Moffett & Moore, 2011; Taylor, 2014). The evolving use of practice guidelines provides another powerful rationale for the inclusion of EBP principles as a core competency for APRNs. The National Guideline Clearinghouse is the largest online resource for clinical practice guidelines (http://guideline.gov/help-and-about). Administered by the AHRQ, this database houses more than 3000 clinical practice guidelines formulated within the past 5 years. The APRN should also search the webpage of the appropriate nursing and medical societies for relevant clinical practice guidelines. The number of professional societies producing clinical practice guidelines has grown from a few pioneers, including the American Academy of Pediatrics and Oncology Nursing Society, to the vast majority of societies and organizations, including many smaller subspecialty groups. The APRN should also search for best practice documents pertaining to the clinical question under scrutiny. Best practice guidelines are a synthesis of expert and clinical opinions when higher levels of evidence are not available to guide clinical decision making (Triano, 2008). Although these documents do not provide the systematic review and evidence-based recommendations of care incorporated into a clinical practice guideline, they can provide an excellent source of current knowledge of a specific intervention or assessment technique. In addition to housing clinical practice guidelines, the National Guideline Clearinghouse also indexes best practice documents produced within the past 5 years. The Registered Nurses' Association of Ontario (RNAO) is another excellent resource for best practice guidelines that affect multiple areas of nursing care, including many areas pertinent to advanced practice nursing (http://rnao.ca/bpg/). Strategies for Searching Electronic Databases Because of their robust size and ability to identify potential resources in a matter of seconds to minutes, any hunt for best current evidence begins with a search of more than one electronic database. Searching multiple databases is strongly suggested because limited evidence has shown that searching a single database is likely to miss meaningful research identified when a search is expanded to more than one database (Bramer, Giustini, & Kramer, 2016). Studies further suggest that even a competent search using appropriate databases fails to identify all of the studies pertaining to a clinical question (Bramer et al., 2016; Helmer, Savoie, Green, & Kazanjian, 2001). An RCT found that the efficiency of identification and retrieval of studies is significantly improved when a medical librarian is consulted (Gardois et al., 2011). Several factors probably contribute to the incomplete retrieval of pertinent studies when relying solely on searches of electronic databases. Challenges related to keywords are postulated to be a primary cause of incomplete retrieval. Many conditions and interventions are referred to by multiple names and these terms evolve over time. For example, the chronic wound currently referred to as a “pressure ulcer” was historically labeled a “bedsore,” a term that was later changed to “decubitus ulcer” or “pressure sore” before the current term was popularized and added to the MESH term taxonomy. In addition to this limitation, electronic databases typically identify keywords for search purposes from the title, abstract, and a short list of key terms provided by the author and/or publisher. Although authors and publishers share the goal of maximizing the number of times an article is read and cited in subsequent peerreviewed publications, even subtle changes in narrative or selection of less widely used terms limit the likelihood that a particular study report will be identified in subsequent searches. Although the lag time between publication and indexing in the major databases has decreased dramatically over the past decade, the significant growth in production of clinical studies by scholars from a number of health care fields means that newer research pertinent to a clinical question typically appears within a matter of months to 1 year of a focused search. In addition, electronic databases are heavily weighted toward published documents. Publication bias is defined as the tendency for studies with provocative results to achieve favorable peer review and acceptance for publication as compared with research reporting negative results (Smith, 1956). In the current era of blended print, electronic, and open access sources of health care research, publication bias arises from multiple sources; specifically, articles are more likely to be published if they report statistically significant findings, or provocative findings that challenge current thinking or are perceived as novel, or if they are likely to attract lay media attention (Song, Hooper, & Loke, 2013). The magnitude of this effect is hypothesized to be substantial (Guyatt et al., 2011). For example, Sutton, Duvall, Tweedie, Abrams, and Jones (2000) carried out metaanalyses of 48 systematic reviews and reported that 20% were found to have omitted or missed studies reporting negative results. Electronic databases are also limited by the relative paucity of gray literature, which is especially significant in nursing research. The term gray literature is defined as unpublished results of studies available as abstracts or short reports in conference proceedings or journal supplements. Sparse research has suggested that the magnitude of nursing studies that remain unpublished despite completion is substantial. For example, Hicks (1995) reported that only 16 of a group of 161 British nurses who completed a study and presented results at a professional conference submitted their findings for publication in a peer-reviewed journal, and only 14 (9%) were ultimately published. Several strategies can be used to increase the proportion of pertinent studies identified during a literature search for current best evidence. They include doing ancestry searches, searching gray literature sources, consulting experts in the field, and using Internetbased search engines. Ancestry searches are completed by reviewing the reference list of individual research reports, review articles, or systematic reviews identified during a literature search (Melnyk & Fineout-Overholt, 2010). Weak evidence suggests that ancestry searches may reveal multiple studies that are missed during electronic database searches (Horsley, Dingwall, & Sampson, 2011). Identifying pertinent gray literature sources remains a challenge. Hand searches of one or more peer-reviewed journals that publish research abstracts in a supplement to or regular issue of the society's official journal, or abstracts made available to conference attendees as a proceedings booklet or in an electronic format, may serve as a rich source of pertinent studies. Although these sources may identify multiple potentially pertinent studies, they typically contain limited details of the study design and analyses of findings, thus limiting their value as evidence-based resources. In contrast, the CINAHL, PsycINFO, and ERIC databases index doctoral theses and dissertations that provide intensely reviewed and detailed reports of graduate students' supervised research. Internet-based search engines, such as Google or Google Scholar, are an increasingly robust source of published and unpublished studies. They are particularly useful when attempting to retrieve full reprints of older articles not yet incorporated into the major electronic databases. Nevertheless, considerable caution must be used when relying on unpublished information from the Internet, especially if the source material has not undergone peer review. An evaluation of the coverage, recall, and precision of search strategies used in 120 systematic reviews found that Google Scholar lacked the full coverage needed for performing a systematic review (Bramer et al., 2016; Gehanno, Rollin, & Darmoni, 2013). Consulting with an experienced researcher or clinical experts in a particular field can also lead to identification of pertinent studies (Godin et al., 2015). Step 3: Critically Appraise and Extract Evidence Although a careful search of the literature using the strategies described will recover pertinent studies, it will also retrieve much information that does not comprise evidence of effectiveness, predictive accuracy, or safety. Therefore, the APRN must critically appraise the various documents for their contribution to current best evidence, extract pertinent data, and set aside findings that do not address the clinical question under scrutiny. This process begins with separation of individual research reports and systematic reviews summarizing research findings from secondary sources, such as integrative review articles or editorials, via a title search. An integrative review is a comprehensive discussion of research, expert opinion, and theoretical knowledge about a topic (Gray & Bliss, 2005). Although the integrative review typically includes studies that may provide valuable sources of evidence when subjected to an ancestry search, it is ultimately a synthesis of knowledge about a given topic, rather than an evidence-based review of studies intended to establish efficacy or predictive accuracy. Similarly, opinion-based articles such as editorials are eliminated because they report expert opinion rather than original research data. Evidence Pyramid After eliminating articles that do not report or systematically review original data, the remaining studies are evaluated based on a pyramid of evidence (Bracke, Howse, & Keim, 2008; Fig. 10.1). The pyramid provides a taxonomy for ranking a study's potential contribution to evidence based on its design. The base of this pyramid comprises laboratory-based studies using animals (in vivo model), tissue samples, cell lines, or chemical media (in vitro models). Although these studies are typically well designed and apply much more rigid controls than those used in clinical research, they are nevertheless eliminated because their findings do not yield evidence about efficacy, safety, or predictive value when an intervention is applied to human subjects in a clinical setting. FIG 10.1 Pyramid illustrating levels of evidence used to evaluate efficacy of an intervention. M-A, Meta-analysis. The second rung up from the base of the evidence pyramid is typically occupied by individual or multiple case series. A case study is a detailed description of results when an individual patient, family, inpatient care unit, long-term care facility, health care system, or community is subjected to an intervention or intervention bundle (Crowe et al., 2011; Polit & Beck, 2016). Multiple case series summarize results from more than one patient with a similar condition when exposed to a common intervention or intervention bundle. The results of case studies or multiple case series can be used as evidence that an intervention is feasible, offers an attractive alternative to usual care, can be applied safely in a selected patient or patients, and merits further investigation to determine clinical effectiveness. However, individual case studies or multiple case series do not compare the intervention of interest with a control or standard care, and their results cannot be used to reach conclusions about efficacy, effectiveness, or predictive power. The APRN must remain aware that findings from these designs tend to favor positive effects of the intervention and often imply evidence of efficacy or effectiveness. In addition, results of individual case studies (sometimes labeled testimonials) are frequently used in marketing campaigns to imply a positive effect when a particular product is used. Nevertheless, case studies and multiple case series do not compare the intervention under scrutiny to a placebo or to standard (usual) care, and their results cannot be used to establish efficacy or predictive power. The higher rungs of the evidence pyramid are occupied by the RCT, nonrandomized comparison cohort trials, and cohort or case-control studies. Depending on the nature of the clinical question and availability of research-based evidence, results of one or more studies employing these designs will be used to determine current best evidence. The nonrandomized comparison cohort trial shares certain similarities with the RCT; it compares outcomes from at least two groups, including one cohort that is exposed to an experimental intervention and a second group exposed to usual care, a sham device, or placebo (Polit & Beck, 2016). However, this study design uses non– randomly selected groups because of ethical, financial, or other considerations. Because the nonrandomized comparison cohort trial lacks random assignment, the potential for bias in group membership is high and the likelihood that these differences will influence study findings is significant. A cohort study is an observational design in which a large sample is identified and followed over time to determine which participants will develop a disease or disorder under scrutiny (Polit & Beck, 2016). During this prolonged observation period, the incidence of the disease or disorder is measured prospectively. A cohort study allows researchers to identify new (incident) cases, and temporal relationships between preventive interventions or constitutional factors and incidence can be analyzed. Although the cohort study provides valuable results, data collection requires an extended observation period, resulting in a comparatively high likelihood of subject dropout and significant cost. The case-control study, sometimes called the nested case-control design, provides a less expensive but less robust alternative to the cohort study. It requires comparison of two groups, one with the condition under study and the other free from the condition at a single point in time. The cohort study prospectively identifies cases from persons who remain free of the disorder of interest, and the nonrandomized comparison cohort study relies on identification of two groups, those with a condition (cases) and a second group without the condition (controls). Selection of this second group (controls) is especially difficult and often acts as a source of bias within this retrospective design (Polit & Beck, 2016). The nested casecontrol study uses retrospective analysis of data from a sample population participating in a parallel group or factorial RCT (Polit & Beck, 2016). These study designs differ from that of the RCT because they are observational rather than interventional in nature. Study findings can be used to identify relationships between the presence of a given factor and the likelihood of the condition being studied, but they cannot be used to establish a cause-and-effect relationship between the associated factor and disease or disorder that is needed to determine efficacy. The most powerful research design is the RCT, which is considered the gold standard for measuring the efficacy of an intervention or the predictive power of an assessment strategy (Sackett, 2015; Turner, 2012). Efficacy is defined as the likelihood that an intervention will achieve the desired outcome in a group of subjects based on evaluation in a research setting that controls for random effects produced by extrinsic factors. The concept of efficacy must be differentiated from effectiveness, which is defined as the effect of a specific intervention when administered to a particular patient at a given point during the course of an illness or condition. Several types of RCTs are commonly reported in the health care literature (Chow & Liu, 2014). The parallel design RCT assigns subjects randomly to an experimental group exposed to the intervention under scrutiny or to a control group exposed to a placebo, sham device, or standard intervention based on ethical considerations. A crossover RCT is characterized by random assignment of subjects to an experimental or control group, followed by crossing the subject over to the alternative group after a washout period designed to remove (wash away) initial exposure effect. Although the crossover RCT potentially needs to enroll fewer total subjects and may incur less cost than the parallel group design, it is performed less often because of the potential for contamination of findings caused by residual effects when subjects are crossed over. The factorial RCT compares two or more experimental interventions with a control group treated with a placebo or sham versus a group receiving usual care or some alternative intervention. Because the RCT is the most powerful study design, it should be routinely included when reviewing the literature for current best evidence; it is generally considered to be of higher quality than designs that do not involve randomization of subjects, such as the cohort or case-control study. Systematic Reviews and Meta-Analyses Even though the RCT is considered the most powerful individual research design, the highest rungs of the evidence pyramid are occupied by systematic reviews and meta-analyses (see Fig. 10.1). These designs form the apex of the evidence pyramid because they combine the results of multiple studies to determine the effect created by a specific intervention. A systematic review uses a structured methodology to comprehensively seek out, select, appraise, and analyze studies based on a measurable clinical question (Engberg, 2008; Holly, Salmond, & Saimbert, 2017). The methods used for generating a systematic review are comparable to those used to identify current best evidence for clinical decision making, and the rise of EBP closely parallels the recent explosion of systematic review articles published in the professional literature. Combining results from multiple studies is more powerful than consideration of a single RCT because it allows for the qualitative analysis of results produced by multiple researchers in various study settings to determine whether the effects of the intervention are beneficial (greater than placebo or standard care), mixed (no more effective than placebo in some studies versus more effective than control group findings in others), or ineffective (less effective than placebo or standard care or associated with adverse side effects that exceed its beneficial effects). The meta-analysis is the highest rung of the level-of-evidence pyramid because it provides a quantitative technique for pooling and analyzing results from more than one study to determine the direction and magnitude of an intervention's effect (Engberg, 2008). Although the benefits of meta-analysis are apparent, studies must be carefully analyzed before completing this type of statistical analysis. This evaluation is based on data extraction and consideration of the sample populations of the various studies, experimental intervention, study methods, and outcome variables used to determine treatment effect. The outcomes of a meta-analysis based on a dichotomous (nominal) outcome measure are usually expressed as an odds ratio, relative risk, or absolute risk reduction, depending on the nature of the clinical question. The results of a meta-analysis based on a continuous outcome variable will be based on the weighted mean difference and standardized mean difference, sometimes referred to as effect size. The precision of the magnitude of the effect size is expressed by the accompanying confidence interval. The level of the evidence pyramid is useful for the APRN engaging in EBP because it provides a taxonomy for categorizing studies based on underlying design for their potential contribution to current best evidence needed to answer a clinical question. Nevertheless, research design alone cannot be used to judge the quality of individual studies or their contribution to current best evidence (Holly et al., 2017). Although RCTs provide excellent designs for minimizing bias in the evaluation of some forms of interventions—a medication designed to improve hemodynamic instability; physical manipulation, such as insertion of a catheter for parenteral fluid replacement; or positioning to prevent ventilator-associated pneumonia—it may not be feasible or desirable to limit a systematic review seeking current best evidence to RCTs alone. In many cases, the APRN will find that there are insufficient RCTs to define current best evidence. As a result, nonrandomized trials or observation epidemiologic studies examining the association between preventive or interventional measures and the outcome of interest may be included because they provide the best available evidence. In other cases, the quality of one or more RCTs may be compromised, limiting the APRN's ability to extract data and reach meaningful conclusions about efficacy from these studies. Ogilvie, Egan, Hamilton, and Petticrew (2005) evaluated systematic reviews of evidence related to the efficacy of psychosocial interventions and observed that the inclusion of RCTs alone might miss most pertinent evidence because these interventions tend to be embedded or applied along with physical interventions in many RCTs. In this case, measuring only direct outcomes produced in an RCT may paradoxically miss results from alternative studies that examine the effect of the psychosocial interventions that comprise an essential component of APRN practice. Critical Appraisal Individual Studies After eliminating studies that do not contribute to determining current best evidence, the APRN must evaluate the quality of individual studies by seeking out sources of potential bias in order to determine the magnitude of their contribution to current best evidence for a given topic (Higgins & Green, 2011). In selected circumstances, this evaluation may be used to eliminate studies that do not meet criteria for meta-analysis or contain sufficient flaws that severely compromise the generalizability of findings. However, studies must not be eliminated because they report negative findings or the study is not an RCT. Although no standardized form for evaluating study quality exists, several models have been developed that provide a useful framework for evaluating the quality of individual studies. Melnyk and Fineout-Overholt (2010) have advocated a Critical Appraisal Guide for Quantitative Studies (Table 10.6). Alternatively, the CONSORT (Consolidated Standards of Reporting Trials) criteria for improving reporting the results of RCTs and the STROBE (Strengthening Reporting of Observational Studies in Epidemiology) criteria for reporting the results of observational studies in epidemiology can be adapted to enable systematic assessment of the quality of individual studies and their contribution to evidence-based clinical decision making (Moher, Schulz, & Altman for the CONSORT Group [Consolidated Standards of Reporting Trials], 2001; von Elm et al. for the STROBE Initiative, 2007). Fig. 10.2 is the individual study form used by the Cochrane Collaboration for evaluating individual studies as part of their production of a systematic review of current best evidence. It is based on a three-level ranking—0 to 2—in which a score of 2 indicates that the criterion was clearly met, a score of 1 indicates that it was partially met, and a score of 0 indicates that it was not met. Tables 10.7 and 10.8 summarize criteria for an initial evaluation of study quality adapted from the CONSORT and STROBE statements, respectively (Moher et al., 2001; von Elm et al., 2007). These statements are designed to serve as a guide when publishing individual study results in a peer-reviewed scholarly journal; they can be easily adapted as a guide for evaluating individual study quality as part of an EBP process. TABLE 10.6 Critical Appraisal Guide for Quantitative Studies Question Evaluation Criteria Why was the study done? Does the study include clearly stated research questions, aims, hypotheses, or purpose statements? What is the sample size? Did the study enroll enough subjects to allow statistical analysis so that results did not occur by chance? Are the instruments used to measure major variables valid and reliable? Were the outcome measures of the study clearly defined? Were instruments used to measure these outcomes valid and reliable? How were data analyzed? What statistical tests were used to determine whether the study purpose was achieved? Were there any untoward events during the study? Did subjects withdraw before completing the study; if so, why did they withdraw? How do results fit with previous research in this area? Did the researchers base their work on a thorough literature review? What does this research mean for clinical practice? Is the study purpose an important clinical issue? Adapted from Melnyk, B. M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Wolters-Kluwer. FIG 10.2 Individual study quality assessment tool. (From the Cochrane Collaboration. [2013]. Study quality guide: Guide for review authors on assessing study quality. Retrieved from https://cccrg.cochrane.org/sites/cccrg.cochrane.org/files/public/uploads/StudyQualityGuide_May%202013.pdf TABLE 10.7 Evaluating Quality of the Randomized Controlled Trial and Nonrandomized Comparison Cohort Trial Criterion Section of the Research Report Study purpose (introduction and background) Study participants (methods) Evidence That Criterion Was Met The purpose of the study is clearly stated. A rationale for the study is clearly stated and supported by appropriate literature. Inclusion and exclusion criteria for study participants are described, along with the study setting. Study aims (methods) Measurable research aims, questions, or hypotheses. These statements include measurable study outcomes consistent with the stated purpose of the study. Sample size (methods) The authors describe how the sample size was determined. Ideally, sample size is based on a power analysis to determine the number of subjects needed to determine group differences. The sample size recruited may be slightly larger than the minimum group size suggested by the power analysis to account for subjects who withdraw prior to completion of data collection. Random allocation (methods) Methods used to achieve random allocation are described, the success of randomization may be illustrated in a table comparing demographic and key clinical characteristics between experimental and control groups, and inferential analysis should identify no significant differences between groups. Procedures for group selection in the nonrandomized comparison cohort trial are described. Absence of randomization in group assignment is clearly acknowledged, and a table comparing demographic and key clinical characteristics of intervention and comparison group is provided. Blinding (methods) Study participants and data collectors are blinded to group assignment whenever feasible; blinding is not feasible for multiple nursing interventions, such as education or counseling. Statistical methods (methods) Appropriate statistical methods are used to compare primary and secondary outcomes. Descriptive statistics and inferential statistical analyses are based on considerations of level of measurement (nominal, ordinal, or continuous) and distribution of data. Multivariate analyses are used when multiple outcome measures are analyzed. Intention to treat analysis is used, when indicated. Participant flow Study procedures are thoroughly described in the methods section; a diagram of (methods and results) participant flow may be placed in the results section. The number of subjects who do not complete data collection is stated, and reasons for early study withdrawal are clearly stated. Ideally, the proportion of patients who do not complete the study is ≤15%. Outcomes (results) Outcomes based on research questions or aims are stated for each group and the precision of the outcomes is measured using a 95% confidence interval. Adverse events Adverse events are reported, along with their impact on study completion. Generalizability Results are interpreted in the context of current evidence along with limitations of the study, including potential sources of bias. Limitations associated with multiple analyses are discussed. Adapted from Moher, D., Schulz, K. F., & Altman, D., & CONSORT Group (Consolidated Standards of Reporting Trials). (2001). The CONSORT statement: Revised recommendations for improving the quality of reports of parallel-group randomized trials. JAMA, 285, 1987– 1991. TABLE 10.8 Evaluating Quality of Observational Studies: Adapted From the STROBE Statement Criterion Section of the Evidence That Criterion Was Met Research Report Study purpose (introduction and background) The purpose of the study is clearly stated. A rationale for the study is clearly stated and supported by appropriate literature. Study participants (methods) Eligibility criteria for study participation and follow-up criteria are clearly described for the cohort study. Criteria for cases and controls are described for the case-control study; criteria used to match cases and controls are clearly described. Study outcomes (methods) Outcome variables are clearly defined, along with confounding factors and potential associated (predictive) factors. Diagnostic criteria for differentiating cases and controls are clearly described for cohort and case control studies. Bias (methods) Statistical methods (methods) Potential sources of bias are acknowledged. Appropriate statistical methods are used to analyze primary and secondary outcome measures. Descriptive statistics and inferential statistical analyses are based on considerations of level of measurement (nominal, ordinal, or continuous) and distribution of data. Multivariate analyses are used when multiple outcome measures are analyzed. An explanation of methods used to control for confounding factors and how missing data were managed is provided. Participants (results) Demographic and pertinent clinical characteristics of cases and controls are described. Outcome data (results) For the cohort study, a report of incidence or summary measures over time should be reported. For the case-control study, outcomes of variables potentially associated with likelihood of status as a case or control subject are reported. Association between outcome as a case or control should be based on multivariate analysis when multiple factors are analyzed. Generalizability (discussion) Key findings are presented based on study questions or aims. Limitations of the study are clearly acknowledged, including sources of bias and inability to determine cause and effect based on the presence of statistically significant associations. Limitations associated with multiple inferential analyses are acknowledged. Adapted from von Elm, E., et al. & STROBE Initiative. (2007). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. BMJ, 335, 806–808. Systematic Reviews and Meta-Analyses Because systematic review and meta-analytic techniques are much newer than the design techniques used to generate RCTs, nonrandomized comparison cohort trials, or observational epidemiologic studies, few instruments have been developed and validated for the evaluation of potential bias in systematic reviews with or without meta-analysis of pooled data. A technical report prepared for the AHRQ identified more than 20 guidelines for evaluating the quality of systematic reviews, but only 2 were considered high quality (West et al., 2002). Nevertheless, this report identified common factors that should be incorporated into any evaluation of the quality of these documents, including a clinical question, methods for searching the literature and extracting data, and recommendations for practice or policy based on evidence identified (Table 10.9). TABLE 10.9 Criteria for Evaluation of a Systematic Review, With or Without a MetaAnalysis Criterion Evidence That Criterion Was Met Study question A clearly defined clinical question is provided; the question should define the patient population and problem, intervention or assessment strategy under scrutiny, comparison treatment, and outcomes indicating intervention effect or predictive power of the assessment strategy. Inclusion or exclusion criteria Search methods are clearly described. Techniques used to identify studies include electronic database searches along with techniques to increase the efficiency of the search, such as ancestry search, consultation with experts in the field of inquiry, web engine searches, trial registries, and conference proceedings. Inclusion and exclusion criteria for studies are clearly stated. Potential sources of bias in selection criteria (time-, language-, and geography-related) are acknowledged and minimized. Data extraction The process for data extraction from individual studies is clearly described. A standardized protocol for data extraction is included in the methods section of the systematic review. This protocol specifies persons involved in data extraction and procedures for coding data, ranking study quality, building consensus about data extraction, and resolving conflicts in individual study coding. Incorporation of an independent coder is used to measure reliability (interrater agreement rates) similar to that used for reporting original data when multiple data collectors participate in a research protocol. Interrater agreement rates should vary from 75% to 100%. A persuasive rationale for excluding studies based on methodologic quality is provided and excluded studies are clearly identified. The process used to weight evidence (e.g., results of meta-analysis, ranking of evidence) is clearly defined. The process for determining study quality, including weighting of the study for purposes of evidence ranking or meta-analysis, is clearly explained. Evidence ranking is based on consensus among authors and a process for resolving disagreements concerning quality rankings via consensus is clearly described. Recommendations for Recommendations for clinical practice are supported by evidence extracted from clinical practice the systematic review. The strength of recommendations should be specified and the process for determining strength of recommendation clearly explained. Ideally, evidence ranking and determination of strength of recommendations for clinical practice are based on validated and published ranking systems. Adapted from Schlosser, R. W. (2007). Appraising the quality of systematic reviews. FOCUS Technical Brief No. 17. Retrieved from http://ktdrr.org/ktlibrary/articles_pubs/ncddrwork/focus/focus17/Focus17.pdf; and West, S., King V., Carey, T. S., Lohr, K. N., McKoy, N., Sutton, S. F., et al. (2002). Systems to rate the strength of scientific evidence. Evidence Report–Technology Assessment No. 47. AHRQ Publication 02-E016. Rockville, MD: Agency for Healthcare Research and Quality. The APRN should evaluate the systematic review for sources of potential bias associated with study retrieval. Common sources of bias include time-, language, and geography-related bias, as well as publication bias (discussed earlier) (Campbell et al., 2015). Time-related bias is created when systematic reviews limit the time frame for study inclusion. Although systematic reviewers are understandably concerned with limiting their reviews to the best current evidence, searches must use original research reports rather than summaries of studies contained in integrative or systematic reviews. Therefore, decisions about time frames in systematic reviews should include the latest publications at the time the review was conducted and extend backward to a meaningful point in time. This time frame may be based on a landmark event, such as passage of legislation, development of an intervention or diagnostic technology, or publication of a Phase 3 RCT and approval of a drug for clinical use. Gaps in the timeline for searches should not be present. Language-related bias is common in systematic reviews. Although English is the predominant language of science (Meneghini & Packer, 2007), and most articles in MEDLINE and CINAHL are published in English, many studies are only published in other languages. The potential for language-related bias associated with the use of English language–only sources should be acknowledged in the methods section or discussion of a systematic review. The Risk of Bias in Systematic Studies (ROBIS) instrument is a validated instrument that was specifically developed for assessment of bias in systematic reviews; it was intentionally designed to reflect the domain-based structure of the instrument used by the Cochrane Collaboration for identifying possible bias in individual studies (Whiting et al. for the Robis group, 2016). The instrument is divided into three phases. In the first phase, the user is prompted to evaluate whether the systematic review adequately adhered to the stated inclusion and exclusion criteria; whether these criteria were clearly stated, mutually exclusive, and unambiguous; and whether these criteria appeared appropriate for the clinical question(s) or aim(s) of the systematic review. The second phase of the instrument includes an evaluation of the techniques used to identify and retrieve studies, such as use of more than one electronic database, selection of search terms, restrictions based on language or publication format, and efforts to minimize errors in study selection. It also prompts users to evaluate the methods used to synthesize findings, extract data, and present findings using appropriate quantitative or semiquantitative criteria such as sensitivity analyses or funnel plots. Phase 3 prompts users to evaluate the methods used to detect sources of potential bias within individuals studies, the relevance of studies based on stated PICO question or review aims, and avoidance of summarizing findings exclusively based on statistical significance. Access to this instrument, along with guidance for its use, is available at http://www.bristol.ac.uk/social-community-medicine/projects/robis/. Data Extraction The decision-making process associated with EBP relies on more than simply retrieving studies and basing a clinical decision on a generalized impression of reported findings. Instead, the APRN should use a consistent process to extract only pertinent outcomes based on criteria determined in the clinical question posed in Step 1. To ensure consistency, study review and data extraction should follow a predetermined protocol, just as original research adheres to established study procedures, regardless of whether results will be used for writing a formal systematic review, evaluating existing evidence for the purposes of a QI project, or formulating new policies in a local facility. The process used to extract data varies based on the nature of the clinical question. For example, the protocol used to extract data from a group of RCTs—possibly combined with results of one or more nonrandomized trials—to determine the efficacy of a given intervention will differ from data coded and extracted for a review of the predictive accuracy of a diagnostic examination. The Cochrane Collaboration (http://bjmt.cochrane.org/resourcesdeveloping-review) provides excellent resources for coding forms enabling a standardized protocol for data extraction. Fig. 10.3 is a data extraction form used for coding data from an individual study evaluating the efficacy of a single experimental intervention. This form can be used when measuring outcomes of trials comparing two groups, one of which was exposed to the intervention of interest and the other exposed to a placebo, sham device, or standard care. The webpage also provides a standardized form designed to aid the clinician when extracting data from RCTs comparing the effects of multiple interventions. FIG 10.3 Data extraction form of individual studies comparing two groups. (From the Cochrane Collaboration. [2013]. Study quality guide: Guide for review authors on assessing study quality. Retrieved from https://cccrg.cochrane.org/sites/cccrg.cochrane.org/files/public/uploads/StudyQualityGuide_May%202013.pdf Step 4: Implement Useful Findings in Clinical Decision Making Implementing useful findings is a deceptively complex process that goes beyond simply combining study results to create a protocol for implementation of a given intervention or assessment strategy. This process occurs on multiple levels, including clinical decision making when caring for an individual patient, creation and implementation of policies on a facility- or community-wide level, and creation of evidence-based clinical practice guidelines designed to set standards of care on a national or global level. Implementing EBP when caring for individual patients, establishing local policies for clinical practice, or establishing guidelines for practice on a national or global basis requires a synthesis of knowledge of the intervention's predictive power or efficacy, consideration of individualized physical and psychosocial factors likely to have an impact on effectiveness when applied to an individual patient, and knowledge of its direct cost or economic impact (van Rijswijk & Gray, 2012). For example, whereas a new drug may be shown to be effective in an RCT when compared with a placebo, its adaptation into an evidence-based clinical practice guideline must also address its comparative effectiveness to existing agents with similar pharmacologic actions, the frequency and nature of the adverse side effects associated with the drug, and its cost. The increased cost associated with a new drug may be justified if it proves more effective than existing agents in the same class or is associated with a lower risk of adverse side effects. In contrast, the novelty of a drug does not provide justification for inclusion in evidence-based clinical practice guidelines or protocols if it does not offer clinically relevant advantages in terms of the efficacy or safety needed to justify the increased patient cost likely to be associated with a newer agent. The process of implementing findings from an EBP process begins with the generation of recommendations for clinical practice, which are derived from the data extracted from pertinent studies. However, just as the strength of individual evidence underlying assessment strategies or interventions varies, so must the strength or associated recommendations for clinical practice. Similar to the various systems used to grade evidence, a review of the literature reveals that more than 60 different taxonomies for grading the strength of practice recommendations have been incorporated into various clinical practice guidelines and best practice documents (Garcia, Alvarado, & Gaxiola, 2010). Widely used systems include the Strength of Recommendation for Treatment taxonomy (SORT) scale, Grading of Recommendations Assessment, Development and Evaluation (GRADE) scales, NICE scale, Center for Preventive Medicine scale (developed in Oxford), and Scottish Intercollegiate Guideline Network (SIGN) taxonomy. Garcia et al. (2010) have compared the effect of evidence-based clinical decision making for a child with diarrhea using four scales (NICE, GRADE, Centre for Evidence-Based Medicine [CEBM], and SIGN scales) in a group of 216 novice physicians (pediatric residents). A significant number of physicians changed their recommendation for management of the index case based on review of the various clinical recommendations. Of the four scales recommended, the GRADE scale was found to exert the greatest influence on clinical decision making. The GRADE scale was developed by a group of clinicians to rank the strength of clinical recommendations based on current best evidence (Atkins et al. for the GRADE Working Group, 2004; Brozek et al., 2009). The GRADE Working Group has recommended evaluating the quality of evidence based on a four-point ordinal scale: 1. High evidence indicates that additional research is unlikely to change confidence of the direction or magnitude of the effect size associated with a specific intervention. 2. Moderate evidence indicates that additional research may significantly influence the magnitude of treatment effect. 3. Low evidence indicates that new research may affect the direction and magnitude of treatment effect. 4. Very low evidence indicates insufficient evidence to determine treatment effect. Using this underlying scale for grading evidence, the GRADE Working Group advocated a scale for recommendations for clinical practice in which the highest grade indicates benefits that clearly outweigh potential for harm, the second level indicates that benefits of treatment must be carefully weighed against potential adverse sides effects, the third level indicates that balance between benefit and harm cannot be clearly distinguished based on best available evidence, and the lowest grade level indicates that the best available evidence suggests the intervention is likely to produce more harm than benefit. A second ranking system will be familiar to many APRNs practicing in North America. The US Preventive Services Task Force uses an ordinal scale with grades ranging from A to D and a fifth category labeled I (Trinite, Cherry, & Marion, 2009). Similar to the rankings advocated by the GRADE Working Group, recommendations for practice are linked to the direction, magnitude, and balance between benefit and harm. Table 10.10 summarizes the Task Force scale for recommendations for clinical practice. TABLE 10.10 US Preventive Services Task Force Scale for Strength of Recommendations for Clinical Practice Rank Description Recommendation for Practice A The service* is recommended and supported by evidence of substantial benefit. The APRN should offer or provide this service when indicated. B The action is recommended and supported by strong evidence of moderate benefit associated with the service, or moderate-level evidence suggesting moderate to substantial benefit from the service. The APRN should offer or provide this service when indicated. C Evidence suggests that the service provides only a small benefit. The APRN should offer or provide this service only when other considerations support offering or providing this service. D Evidence demonstrates no benefit from the service or potential harm outweighs the service. The APRN should discourage use of the service. I Current evidence is insufficient to assess the balance between harm and benefit of the service. The APRN should counsel patients about the uncertainty of the balance between benefit and harm before offering or providing this service. * Service is defined as an intervention, intervention bundle, or assessment strategy. From Trinite, T., Cherry, C. L., & Marion, L. (2009). The U.S. Preventive Services Task Force: An evidence-based prevention resource for nurse practitioners. Journal of the American Academy of Nurse Practitioners, 21, 301–306. From Policy to Practice: Tips for Achieving Meaningful Changes in Practice Based on Current Best Evidence Although the EBP process is effective for identifying current best evidence, completion of the process does not guarantee meaningful changes in practice needed to achieve desired clinical outcomes. In contrast, evidence strongly suggests that merely introducing a new policy or directing clinicians to alter their current practice is unlikely to lead to meaningful or sustained changes in practice (West, 2001). Many EBP innovations introduced through the efforts of one or more clinician advocates tend to result in short-term adoption by a limited number of clinicians that is not likely to be sustained over time (Stetler, 2003). To overcome this problem, the APRN must be aware of successful strategies to design and implement a structured program for translating practice innovations into meaningful and sustained changes. Rogers' Diffusion of Innovation Theory provides a useful framework for the APRN seeking to implement successful and sustained changes in practice based on EBP processes (Rogers, 2003). This theoretical framework describes four stages that an individual clinician or group will experience when evaluating and deciding to adopt or reject a practice innovation. The first phase, described as the knowledge stage, occurs when clinicians are made aware of the innovation and its potential impact on practice and patient outcomes. For many clinicians, knowledge may be introduced through continuing education activities, announcement of a practice innovation, or informal communication from colleagues or informal clinical leaders. Historically, many clinicians have believed that simply introducing a practice innovation is sufficient to ensure a sustained practice change, but research utilization studies have repeatedly proven this assumption false (Rogers, 2003; Stetler, 2003). The second stage is characterized by a process of persuasion. During this stage, clinicians will form a favorable or unfavorable attitude toward a practice innovation. Although the decision-making process is highly individualized, formation of a positive attitude toward a practice innovation is primarily determined by two major factors—the perceived benefit of the practice change on patient outcomes and the perceived investment associated with the practice change as compared with current practice. Outcomes of research studies tend to focus on benefits to patients, but the APRN must also carefully consider the impact of a proposed practice innovation on existing practice. Such considerations are particularly relevant when an EBP innovation comprises a bundle of interventions. For example, current best evidence reveals that prevention of facility-acquired pressure ulcers is based on a number of preventive interventions, including regular skin assessment, pressure ulcer risk assessment, selective use of support surfaces, and regular patient turning and repositioning (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2014). Research has also demonstrated that pressure ulcer risk assessment is more effective when based on a validated instrument as compared with an individual clinician's judgment. Various pressure ulcer risk instruments have been validated, but the Braden Scale for Pressure Sore Risk has emerged as being predominant in North America (Bolton, 2007). This is not based on its predictive power alone; a number of scales have been shown to exert robust predictive power in evaluating pressure ulcer risk. Rather, clinical experience overwhelmingly suggests that the parsimony of the Braden scale profoundly influences it predominance in clinical practice, especially when compared with other scales that require far longer to complete. The third phase (decision stage) occurs when individual clinicians reach a decision about the proposed practice innovation (Rogers, 2003). At this point, the clinician will elect to support (accept) the practice innovation as valuable and worthy of implementation or oppose (reject) the innovation as offering insufficient benefit for the patient or being too costly when compared with outcomes achieved using current practice patterns. Historically, the decision to accept or oppose a practice innovation when reached by a key decision maker, such as a physician or nurse administrator, was thought to be the same as adopting or rejecting it, but the rise of EBP and interprofessional care teams has led to a more transparent separation of individual decision making from adoption of a practice innovation. The final stage of innovation diffusion is adoption into daily clinical practice. Similar to the other stages of innovation diffusion, successful adoption requires more than assent to integrate the innovation into practice. It also requires varying levels of adapting or restructuring the practice environment in a manner that enables clinicians to engage in the behavior changes needed to adopt an innovation. When planning to introduce an EBP innovation, the APRN should consider the following factors: (1) its relative advantage; (2) its compatibility with current practice patterns; (3) the degree to which the innovation can be adapted on a trial basis; and (4) the degree to which results of the innovation can be observed (Rogers, 2003). Judging the relative advantage of a practice innovation requires comparing the time required to execute its various assessments and innovations as compared with the time and effort committed to existing practice patterns. Demonstrating the relative advantage of an EBP innovation is particularly challenging when it requires a greater time investment than current practice patterns. In this case, the APRN should clearly communicate and emphasize advantages to patient outcomes. Additional factors that favor adoption of an EBP include support from organizational administration, clinical leadership at the inpatient unit or clinic level, and manipulation of the practice environment to enhance adoption of new practices. The degree to which a practice innovation can be adopted on a trial basis can also enhance the likelihood of its successful and sustained adoption (Rogers, 2003). For example, implementation of a facilityacquired pressure ulcer prevention program might include risk assessment using the Braden Scale for Predicting Pressure Sore Risk. In this case, integration of the Braden scale into the hospital's electronic medical record, combined with an online training program, allows nurses to familiarize themselves with use of the instrument prior to officially adopting this assessment into routine practice (Magnan & Maklebust, 2008, 2009). Adoption of an EBP innovation is also enhanced by the degree to which results are observable. Meaningful feedback has traditionally been reserved for administrators or selected clinical leaders. However, front-line clinicians must be included in this feedback loop if they are to adopt practice changes on a sustained basis. The process of implementing EBP in the APRN's local facility must be individualized based on existing practice patterns, staffing and resources of the facility, and organizational culture of the facility (Carlson, Rapp, & Eichler, 2012). Nevertheless, experience and existing research provide insights into key elements needed for achieving a successful and sustained change in practice patterns: (1) identification of an interprofessional team of stakeholders needed to plan and implement the practice innovation; (2) support from the organization's administration; (3) a clinical leadership structure that supports EBP principles; and (4) feedback data for monitoring improvement and rewarding clinician stakeholders. Stakeholder Engagement Formation of an interprofessional team of key stakeholders is essential to the implementation of a successful and sustained EBP innovation (Gallagher-Ford, Fineout-Overholt, Melnyk, & Stillwell, 2011; Powell, Doig, Hackley, Leslie, & Tillman, 2012). This group should include key clinical leaders who will be affected by the proposed practice innovation, such as clinical nursing leaders, physicians, and other clinicians (e.g., physical or occupational therapists, case managers). This group will be most directly responsible for completing the initial EBP process to identify current best evidence or using available resources, such as clinical practice guidelines, to aid with this determination. This group should also take primary responsibility for determining how the practice innovation should be incorporated into existing practice patterns. The key stakeholder group must consider a number of factors when designing an implementation strategy, including potential facilitators and barriers to implementation. Although evidence is limited, Weiner, Amick, and Lee (2008) have provided a detailed description of strategies that have proven effective for assessing organizational culture and barriers or facilitators likely to influence introduction of an EBP innovation. The core group should also design strategies to gain administrative support and support from key clinical leaders essential to the implementation of an EBP innovation. An APRN is often the coordinator or leader of this interprofessional team. Organizational Support In some cases, administrative personnel may approach the APRN concerning the need for a practice innovation based on regulatory changes, such as the introduction of “never events” by the National Quality Forum and Centers for Medicare and Medicaid Services in 2008 (Drake-Land, 2008). However, clinical experience strongly suggests that most EBP innovations are initiated by a clinician seeking to improve patient care outcomes. Ensuring administrative support involves more than merely informing administrative personnel of an intention to change organizational practice based on EBP principles (Brindle, Creehan, Black, & Zimmerman, 2015). Instead, the APRN must work with other key stakeholders to formulate a proposal that provides key administrative personnel with knowledge of the rationale for the recommended practice innovation, its anticipated impact on patient outcomes and associated costs, and the extent of needed resources, which will vary depending on the practice innovation proposed. Essential resources usually include a commitment to clinical leaders and staff education about the proposed practice innovation, alterations to the electronic health record needed to facilitate the innovation, disposable supplies or durable medical equipment needed to implement the practice change, and a system for measuring outcomes and providing staff and stakeholders with meaningful feedback about outcomes. Clinical Leadership Support The presence of a corporate culture and clinical leadership structure that supports EBP principles may be the single most important factor influencing the adoption of EBP innovations (Creehan et al., 2016; Rapp et al., 2010). Rapp et al. (2010) evaluated barriers to the implementation of EBP initiatives and observed that the behavior of clinical supervisors forms a substantial barrier to statewide EBP innovation projects. Specifically, they found that although clinical leaders did not oppose the use of EBP principles for clinical decision making, they did not set expectations among front-line clinicians, relying instead on informal methods of practice adoption. Although this approach may not act as a barrier to select clinicians who share an inherent interest in EBP and practice innovation, it ultimately favors maintenance of the status quo rather than organizational adoption of EBP principles and associated practice innovations. Fortunately, several strategies have been identified to avoid this potential barrier to the adoption of EBP innovations. Obtaining Magnet status is a strategy for promoting an organizational environment that promotes EBP in nursing practice. Magnet status from the American Nurses Credentialing Center requires the integration of EBP principles into nursing care (Reigle et al., 2008). Although obtaining Magnet status is a major undertaking that goes well beyond the implementation of a single EBP innovation, it has been shown to aid facilities when transforming an organizational culture to one that promotes the principles of EBP among clinical nursing leaders and front-line clinicians. Involvement of clinical leadership facilitates unit- or facility-based adoption of EBP practice innovations. Clinical leaders, such as the clinical nurse specialist, may act as facility-wide leaders for EBP changes by working with an interprofessional team evaluating facility-wide or health system–wide policies and procedures for care delivery. The clinical nurse specialist also may act as mentor and educator for unit- or clinic-based champions, which has been shown to facilitate adoption of EBP innovations in multiple health care settings (Taggart, McKenna, Stoelting, Kirkbride, & Mottar, 2012; Yevchak et al., 2014). The unit- or clinic-based champion is a clinician who practices on the unit in question and agrees to act as a mentor to front-line staff nurses and others to implement the EBP innovation. Selection of the proper individual as a champion is critical; Rogers (2003) noted that group adoption of innovation occurs in a stepwise manner, with some individuals acting as early adopters, followed by most group members who adopt the innovation based on positive results and feedback from early adopters, followed by a second minority of individuals (late adopters) who change practice only after it becomes apparent that the innovation is inevitable. Clinicians who are early adopters, and who are recognized on their units as influential practitioners, are preferred to the appointment of clinicians who are not persuaded that the innovation is advantageous when compared with current practice patterns. Beyond careful selection and adequate administrative support, limited research allows identification of some fundamental strategies that enhance the effectiveness of unit-based champions (Taggart et al., 2012; Yevchak et al., 2014). These include scheduling time for unitbased champions to receive essential education for their enhanced role and to meet with clinical experts and unit managers as their role is delineated. Production and distribution of easily accessible educational materials for staff, including online information, pocket cards, and traditional education sessions tailored to staff with varying work hours, have been shown to enhance the effectiveness of unitbased champions on daily practice. Specific strategies such as rounding or case presentations are also perceived as valuable, as is quick access to specialty practice nursing or interprofessional staff. Evidence-Based Practice Innovation: Feedback As noted earlier, generating objective and meaningful outcomes when engaging in an EBP change is essential to determine its impact on clinical outcomes and cost. Feedback should be easily interpretable to all stakeholders and provided on a regular basis to promote sustained changes. For example, feedback may include regular reporting of facility-wide pertinent clinical outcomes, such as reduction in surgical site infections or indwelling catheter days, or it may include individual provider or unit outcomes. While the concept of providing feedback as a means of engaging clinical staff in an EBP innovation seems attractive, evidence concerning its impact is mixed. For example, a study of a structured monthly feedback program on a ventilator care prevention bundle in two urban critical care units found no effect on adherence after 1 year (Lawrence & Fulbrook, 2012). Similarly, researchers conducted an RCT that analyzed the impact of a monthly, multifaceted feedback strategy on nursing shifts (the unit of analysis for this cluster RCT) in 24 Dutch intensive care units limited to quarterly feedback (de Vos et al., 2015). No differences in adherence to evidence-based guideline standards were found when the structured feedback intervention was compared to standard feedback. Whether these results reflect the lack of efficacy of any structured feedback program versus lack of effect owing to the nature of the feedback is not clear. Additional research is needed before recommendations concerning routine feedback for front-line clinicians participating in an EBP innovation can be made. Future Perspectives The identification and evaluation of studies to identify current best evidence is currently based on a hierarchy that identifies the RCT as the most powerful study design for generating evidence, along with systematic reviews and meta-analytic techniques that combine data from multiple RCTs to reach conclusions about the strength of evidence. Although the RCT remains the best research design for evaluating the efficacy of an intervention, it does not necessarily follow that determination of efficacy indicates that an intervention will prove effective when applied in daily clinical practice as opposed to the rigidly controlled clinical trial setting (van Rijswijk & Gray, 2012). In addition, evaluations of current best evidence do not incorporate other real-world factors that influence treatment effectiveness when applied to the management of individual patients, including patient preference and the impact of cost. In order to address these gaps, clinicians, researchers, and policy makers are working together to look at sources of real-world data as complementary to data generated from traditional research designs, including the RCT. For example, in 2010, Congress allocated funds for development and generation of comparative effectiveness studies that seek to measure clinical effectiveness based on considerations of treatment effect, patient preference, and resource allocation (2010; U.S. Department of Health and Human Services, Health Resources and Services Administration, 2011). At the same time, the National Institutes of Health formed the Patient-Centered Outcomes Research Institute (PCORI), which was charged with generating research to help patients and providers make more informed decisions about their own care. The Institute continues to fund comparative effectiveness studies. This approach differs from traditional EBP processes because it relies on data collected under daily clinical practice and outside the controlled environment of the RCT (AHRQ, 2016). Other sources of real-world data include real-world clinical trials and health sciences research. The essential components of a welldesigned, real-world trial continue to evolve, but basic principles include comparison of existing options for treatment; enrolling participants with few inclusion and exclusion criteria; minimal or no manipulation of treatment interventions outside individual clinical judgment; and consideration of treatment effect, cost, and patient preference (Lurie & Morgan, 2013). Health services research is generated by an interprofessional or transdisciplinary research team that investigates how social factors, financing systems, organizational structures, technologies, and individual behaviors affect access to health care (Lohr & Steinwachs, 2002). In addition, large electronic databases provide an increasingly rich source of real-world data that extends knowledge of how interventions perform beyond that provided by the RCT. Conclusion EBP involves the generation of a clinically measurable question, identification of pertinent research findings, coding and extraction of essential data, and implementation of findings. Intimate knowledge of this process is critical for the APRN to master three core levels of the EBP competency: application to individual clinical decision making, formulating policies for patient care in a local facility, and evaluating evidence in order to establish standards of care via clinical practice guidelines. These competencies are increasingly essential as the APRN functions as a team member, leader, and decision maker within an interprofessional health care team. Key Summary Points ■ Evidence-based practice is a central competency of advanced practice nursing. ■ Evidence-based clinical decision making arises from a four-step process beginning with identification of a pertinent clinical question, systematic literature review, extraction of pertinent data, and implementation of findings into clinical practice. ■ The APRN is well prepared to synthesize existing research findings needed to translate current best evidence into clinical practice on an individual, unitwide, facility-wide, or health system–wide basis. ■ Translating current best evidence into clinical practice requires more than simply introducing new policies or procedures in order to achieve meaningful or sustained changes in clinical practice. ■ Formation of an interprofessional team of key stakeholders, clinical support, and clinical leadership on a facility-wide level from an APRN and others, along with unit-based support from clinical champions, is essential for achieving sustained changes in clinical practice. 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Clinical Nursing Research. 2014;23:201–215. a Grey literature are document types that are protected by intellectual property rights and of sufficient quality to be collected and preserved by libraries and institutional repositories, but they are not controlled by commercial publishers. C H A P T E R 11 Leadership Michael Carter, Laura Reed “Anyone can hold the helm when the sea is calm.” —Pubilius Syrus CHAPTER CONTENTS The Importance of Leadership for APRNs, 256 Constantly Evolving Health Care Systems, 257 Evolving Health Professional Education, 258 APRN Competencies, 258 Leadership: Definitions, Models, and Concepts, 259 Definitions of Leadership Useful for APRNs, 259 Leadership Models That Address System Change and Innovation, 261 Concepts Related to Change, 262 Types of Leadership for APRNs, 264 Clinical Leadership, 265 Professional Leadership, 266 Systems Leadership, 266 Health Policy Leadership, 267 Characteristics of APRN Leadership Competency, 269 Mentoring, 269 Empowering Others, 270 Innovation, 271 Political Activism, 271 Attributes of Effective APRN Leaders, 272 Timing, 272 Self-Confidence and Risk Taking, 273 Communication and Relationship Building, 273 Boundary Management: Balancing Professional and Personal Life, 274 Self-Management/Emotional Intelligence, 274 Respect for Cultural and Gender Diversity, 275 Global Awareness, 275 Developing Skills as APRN Leaders, 276 Factors Influencing Leadership Development, 276 Personal Characteristics and Experiences, 277 Strategies for Acquiring Competency as a Leader, 277 Developing Leadership in the Health Policy Arena, 277 Using Professional Organizations to the Best Advantage, 279 Internships and Fellowships, 279 New Modes of Communication, 279 Obstacles to Leadership Development and Effective Leadership, 279 Clinical Leadership Issues, 279 Professional and System Obstacles, 280 Dysfunctional Leadership Styles, 280 Horizontal Violence, 280 Strategies for Implementing the Leadership Competency, 283 Developing a Leadership Portfolio, 283 Promoting Collaboration Among APRN Groups, 283 Networking, 283 Effectively Working With Other Leaders to Advance Health Care, 284 Institutional Assessment Regarding Readiness for Change, 284 Followship, 284 Conclusion, 285 Key Summary Points, 285 The authors acknowledge Charlene Hanson and Mary Fran Tracy for their contributions to earlier editions of this chapter. The purposes of this chapter are to describe the advanced practice registered nurse (APRN) leadership competency, provide useful literature and resources on leadership and change, describe characteristics of effective leaders, identify obstacles to effective leadership, and discuss strategies for developing leadership skills. This chapter will help APRNs define their need for leadership abilities and develop a plan for acquiring the necessary skills appropriate to their particular positions and professional goals. The Importance of Leadership for APRNs Leadership is a core competency of APRNs. This competency may come as a surprise to some new APRNs in that they are often focused so much on understanding and applying the art and science of clinical practice that leadership seems like a distant concern. Yet APRNs quickly learn in clinical practice that care is provided in complex systems and these systems require leadership to function effectively. APRNs have unique knowledge and clinical legitimacy that provide a strong basis for their leadership. Health care systems are under constant redesign and transformation (Gilman, Chokshi, Bowen, Rugen, & Cox, 2014; Institute for Healthcare Improvement [IHI], 2011; Institute of Medicine [IOM], 2000, 2001, 2011; Leape et al., 2009; Reynolds et al., 2015), and there is continuing evolution in health professional education as well (American Association of Colleges of Nursing [AACN], 2006; Dreher, Clinton, & Sperhac, 2014). Interprofessional care among a variety of different clinicians has become more important to ensure quality outcomes, and leading these teams is very complex (Canadian Interprofessional Health Collaborative, 2010; Farrell, Payne, & Heye, 2015; Greiner & Knebel, 2003; Interprofessional Education Collaborative, 2011). The unique leadership provided by APRNs takes place in the systems where they provide care. Clinical care is usually delivered at the individual, patient level but is embedded within larger organizations. These larger care delivery organizations rely on leaders to improve safety, quality, and reliability and to evaluate the results of care. In short, systems leaders must be able to identify the need for innovation and change and implement strategies to achieve them. In partnership with others, APRNs craft approaches to evaluate, reassess, and implement systems redesign and innovation. APRNs provide leadership in several areas. Their activities range from taking a stand on behalf of an individual patient to advocating for a change in national health policy. Competency in leadership does not stand alone but interacts with other APRN competencies. In the United States, the movement of APRN education to the Doctor of Nursing Practice (DNP) has implications for the APRN's leadership competency (AACN, 2004). For example, one of the essentials of DNP education is expertise in systems leadership (AACN, 2006). Constantly Evolving Health Care Systems The World Health Organization (2013) has reasoned that everyone in the world should have access to the health services they need without being forced into poverty when paying for these services. This goal requires substantial changes in the health systems of many countries, including the United States. The passage of the Patient Protection and Affordable Care Act (2010) and the subsequent enactment of the Act's many provisions moved the United States much closer to universal coverage, but the United States remains the only developed country in the world without universal coverage. Other nations are experiencing similar evolution of their systems of care, and these changes are often related to the new types of health care problems seen in these countries, the organization of their health care systems, and the ways in which these countries pay for care. The IOM released their groundbreaking The Future of Nursing report in the United States in 2011, and the subsequent work in monitoring these changes highlights the important goals for APRNs to lead change and advance health. This report contends that it is essential for nurses to be full partners and leaders in the transformation of health care. The IOM has issued a number of reports over the years calling for radical redesign and transformation of the American health care system. Such changes do not occur quickly in part because they require a significant rethinking of how care is delivered, the roles of patients and education of providers, effective channels for diffusing innovation, how health care is financed, where and how care is delivered, and which provider activities are valued and paid for (Hunter, Nelson, & Birmingham, 2013). These IOM reports calling for transformation of the health care system are predicated on six national quality aims—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (IOM, 2001). The IOM has long noted that patients throughout the health system are at high risk for the occurrence of adverse events, yet numerous institutional barriers to reporting these events still exist. One barrier has been the longstanding tendency toward naming and blaming individuals rather than exploring gaps in systems of care and organizational culture (Wagner, Capezuti, & Ouslander, 2006). Leaders have come to realize that errors occur because of a continuum of reasons. APRN leaders can use the six quality aims to facilitate the evaluation of errors, near misses, and questionable behavior to determine root causes of situations in which employee behavior does not match organizational values. Causes for these situations can range from organizational culture to defective systems and processes to bad choices on the part of employees. The IHI launched a campaign in 2001 to save 100,000 lives from medical errors (Berwick, Caulkins, McCannon, & Hackbarth, 2006; Patient Safety and Quality Health Care, 2005). This campaign was so successful, with an estimated 122,000 lives saved between January 2005 and June 2006, that a new goal was created to decrease mortality and morbidity in 5 million lives (IHI, 2012). Yet with all these efforts, medical errors remain the third leading cause of death in the United States per year, estimated to total 251,454 deaths (Makary & Daniel, 2016). Many health care systems are participating in efforts to improve safety and quality, such as Magnet hospital recognition or participation in the IHI campaign. APRNs not only have a stake in these efforts but also have the clinical expertise and leadership that can ensure success. Evolving Health Professional Education Just as health care has been evolving throughout the world, so too has health professional education. Part of these educational changes reflect the new or expanded competencies health professionals must have for future practice based on changes in the type of health care conditions being treated and new emphasis being placed on patient quality, costs, access, and patient-centered care. The Josiah Macy Jr. Foundation makes recommendations on how health care providers need to be trained to meet the needs of primary health care and has been providing yearly updates on interprofessional education (Cronenwett & Dzau, 2010; Kahaleh, Danielson, Franson, Nuffer, & Umland, 2015; Pohl, Hanson, Newland, & Cronenwett, 2010). There continues to be substantial interest in expanding and improving interprofessional education. This approach to education is very complex in that health professionals come from different theoretical perspectives, educational programs may not be co-located, academic calendars are seldom synchronized, and faculty obligations often preclude working with other professions. Measuring the impact of interprofessional education on provider practice and the outcomes for patients has been very difficult. This may be attributed to the substantial length of time from when the professionals were in education until actual changes in patient outcomes could be measured. In addition, the system of care delivery is changing the way it is financed, and this can compound the measurement of outcomes from education alone. APRN Competencies In the AACN's The Essentials of Doctoral Education for Advanced Nursing Practice (2006), several specific competencies relate to leadership for all DNP graduates, including APRNs. Of the eight essentials, four inform the leadership competency—organizational and system leadership for quality improvement and systems thinking, clinical scholarship and analytic methods, information systems and patient care technology for the improvement and transformation of health care, and clinical prevention and population health for improving the nation's health. Core competencies developed by the National Association of Clinical Nurse Specialists (NACNS, 2010) address leadership requirements of clinical nurse specialists (CNSs), and those developed by the National Organization of Nurse Practitioner Faculties (NONPF, 2017) address nurse practitioners (NPs). Nurse practitioner leadership competencies are also in place for Canada (Canadian Nurses Association, 2010) and Australia (Nursing and Midwifery Board of Australia, 2014). Earlier APRN education programs focused a good deal on learning to provide expert clinical care. This focus was necessary but is no longer sufficient for future practice. Health care has changed in many ways. Practice today and for the future means that APRNs must possess knowledge, skills, and abilities to address larger system issues in a way not expected in the past. APRNs have a social covenant with the society that they serve. New issues concerning the social determinants of health have emerged and must be understood by APRNs. Patients are living longer and some of this extension of life includes periods of active dying. Many health conditions have no cure or hope of cure. Learning to diagnose and treat patients with acute and chronic health conditions is central for much of APRN practice, but the work does not stop there. Understanding the evolving structures, regulations, and ethos of care is mandatory for APRNs to deliver high-quality care with the greatest access for those in need and at the lowest costs. These changes in focus of care mean that APRNs must be able to seamlessly move from the individual recipient of the service to the much larger system context and then back. In summary, numerous contextual and educational factors that require APRN leadership have been identified in calls for the redesign and transformation of the health care system. Certain themes are apparent—in particular, patient-centeredness (see Chapter 7), teamwork (see Chapter 12), quality improvement, the use of information technology, and complexity. These factors are an appropriate part of graduate and continuing education so that APRNs acquire the knowledge and skills they need to lead effectively (Cronenwett et al., 2009; Scott & Miles, 2013; Sherwood, 2010). Leadership: Definitions, Models, and Concepts APRNs can draw on numerous models of leadership and change processes to inform their leadership development. Most leadership models are predicated on leaders having an ability to understand themselves. Leadership grows out of personal characteristics that can be learned and are associated with successful leadership. One model of self-awareness is the emotional awareness model of Goleman (2005). This model proposes that there are four core skills that lead to improved leadership effectiveness. These are self-awareness, selfmanagement, social awareness, and relationship management. Most important is that successful leaders understand the importance of selfregulation in their relationships. Definitions of Leadership Useful for APRNs Contemporary definitions of leadership generally fit into one of two categories: transformational leadership (Carlton, Holsinger, Riddell, & Bush, 2015; Vance & Larson, 2002) or situational leadership (Carlton et al., 2015; Grohar-Murray & DiCroce, 1992). Both categories are built on attributes of the leader that are learned and can be taught. Leadership Models That Lead to Transformation Vernon (2015) asserted that transformational leaders constantly ask themselves and their team questions about what the goal is, how to try things differently, and what are the costs of maintaining the status quo. This form of leadership transforms the team by leading to changes in values, attitudes, perceptions, and/or behaviors on the part of the leader and the follower and lays the groundwork for further positive change. Thus, transformational leadership occurs when people interact in ways that inspire higher levels of motivation and morality among participants. How do leaders do this? Transformational leaders analyze a situation to understand the particular leadership needs and goals; they use this information, together with their interpersonal skills, to motivate, stimulate, share with, conciliate, and satisfy their followers in an interdependent interactional exchange. DePree (2011) defined leadership as an art form in which the leader does what is required in the most effective and humane way. This definition proposes that contemporary leadership may be viewed as a process of moving the self and others toward a shared vision that becomes a shared reality. Successful transformational leadership is relational, driven by a common goal or purpose, and satisfies the needs of leader and followers. It is the leadership style often associated with effective change agents. Schwartz, Spencer, Wilson, and Wood (2011) have studied the effects of transformational leadership on the Magnet designation for hospitals and report that transformational leadership brought about the change needed to obtain and maintain Magnet status. Other authors who have described a transformational approach to leadership include Wang, Chontawan, and Nantsupawat (2012), who studied transformational leadership with Chinese nurses. Transformational leadership was associated with job satisfaction in nurses. Many different models of leadership are available (Table 11.1). One model that is frequently used is the work of Stephen Covey, begun in 1989. TABLE 11.1 The Eight Habits of Highly Effective People Stephen Covey (1989) presented personal and interdependent characteristics that foster acquisition of leadership skills (Box 11.1). In creating a personal view of leadership, Covey suggested that the most effective way to “keep the end in mind” is to create a personal mission statement that becomes a standard to live by as one progresses from independence to interdependence. In Covey's model, interdependence is achieved only after one has defined and integrated this personal mission or standard into one's practice. Covey described attributes of those who lead from a philosophy of interdependence: listening twice as much as you speak, remaining trustworthy by never compromising honesty, maintaining a positive attitude, and keeping a sense of humor. Interdependence allows one to hear and understand the other person's viewpoint, leading to a synergistic or win-win level of communication. In 2004, Covey expanded on this leadership model by proposing an eighth habit—leaders need to find their voice and help others to find theirs. He noted that leaders at any level can use their inspiration and influence to overcome negativity and use creativity to move the organization to greatness; this type of leader can be a catalyst for change. Covey (2006) also developed leadership ideas in light of managing people in the information age. A key concept in this update is that leaders must be aware that the ways they lead will influence the choices that followers make. Box 11.1 Covey's Eight Habits of Highly Successful People • Be proactive. • Begin with the end in mind. • Put first things first. • Think win-win. • Seek first to understand, then to be understood. • Synergize. • Sharpen the saw. • Find your voice and inspire others to find theirs. Adapted from Covey, S. (1989). The seven habits of highly effective people: Powerful lessons in personal change. New York, NY: Simon & Schuster; Covey, S. (2004). The 8th habit. From effectiveness to greatness. New York, NY: Free Press; and Covey, S. (2006). Leading in the knowledge worker age. Leader to Leader Journal, 41, 11–15. Situational Leadership The term situational leadership is defined as the interaction between an individual's leadership style and the features of the environment or situation in which he or she is operating. Leadership styles are not fixed and may vary based on the issues being addressed or on the environment. Situational leadership depends on particular circumstances, with leaders and followers assuming interchangeable roles according to environmental demands (Huber, 2014). The role of follower is important because APRNs will find themselves in both roles from time to time. Leaders must have followers and followers must have leaders. It is important for leaders to learn to follow and allow others to lead. DePree (2011) expanded on this idea and used the term roving leadership to describe a participatory process in which leadership in a particular situation may shift among the team members. This notion of leadership is relevant because APRNs' work in collaborative health care teams requires the roles of leader and follower to be interchangeable depending on the complex needs of the patient. Leadership Models That Address System Change and Innovation Change is a constant in today's clinical environments. Efforts to transform the health care system are generally focused in three areas: diffusion of innovation, clinician behavior change, and patient behavior change. The reality is that change is often messy and not always welcome even when it seems straightforward. An integrative review of diffusion and dissemination of innovations reveals why redesign and transformation are messy—they are exceedingly complex (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004; Kwamie, 2015). For example, an NP was very concerned about how long it was taking patients to schedule return visits. The booking system was controlled by the larger health care organization and was not easily adapted to a specific purpose. In addition, all the providers wanted to keep all slots filled for the next 2 weeks so double booking was common, resulting in some clinic times being overloaded. Office staff had no authority to override the system and billing staff could not determine if a particular insurance plan would pay for more frequent visits. Making any change in scheduling involved the information technology staff, the office staff, the billing staff, and the clinicians—any one of whom could stop the change. Nelson et al. (2002) argued that clinical microsystems are the frontline units in which patients and providers interface and are the foundation for providing safe and high-quality care within large organizations. Thus transforming care at the front-line unit is essential to optimizing care throughout the continuum. They studied the processes and methods of 20 high-performing sites and identified the characteristics that were related to high performance: leadership, organizational culture, macro-organizational support of microsystems, patient focus, staff focus, interdependence of the care team, information and information technology, performance improvement, and performance patterns. APRNs practice at the patient-provider interface, and their leadership can contribute greatly to the optimization of other successful characteristics. APRNs are skilled at creating cohesive teams, identifying and advocating patient and staff needs, leading performance-improvement efforts at the front-line interface, and contributing to a positive organizational culture. One helpful model for understanding leadership in complex organizations is complexity theory. Henry (2014) contends that complexity theory is focused on understanding the ways in which individuals are free to act in interconnected but not predictable ways. This means that one person's actions lead to changes in the context for others in the organization. Some theories of leadership and management are built on the assumption that individuals and organizations are logical and predictable in the way they function. Complexity theory holds that some actions are not predictable in a linear manner and evolve more organically. APRNs who are learning to lead change may find the use of complexity theory helpful. Clancy, Effkin, and Presut (2008) provide insights when there are multiple providers, new technology competition, and complex information systems involved. Spread of Innovation Massoud and colleagues (2006) developed a model to address the difficulty in spreading effective, evidence-based innovation beyond the immediate environment. Diffusion within and among health care organizations is key with today's goal of implementing best practices throughout health care. Founded on Rogers' (2003) definition of diffusion, this framework for spread is based on four main components—preparing for spread, establishing an aim for spread, developing an initial spread plan, and executing or refining the spread plan. Leadership is essential in preparing a plan to spread innovation. As leaders, APRNs must take an active role in ensuring the innovation is evidence based throughout all aspects of the spread plan. During the development of the spread plan, the leader oversees the project and may take an active role in developing the plan. Finally, the APRN leader needs to ensure collection and use of information about the effectiveness of the plan, supporting course correction as needed. Several common themes emerge when considering models of leadership and change. Effective leadership requires sound knowledge of oneself and one's organization with regard to values, strengths, and weaknesses, as well as expert communication and relationship-building skills and the ability to think and act strategically. Appreciative Inquiry Appreciative inquiry (AI) is a leadership model that seeks to find positives through appreciative conversations and relationship building (Cooperrider, Whitney, & Stavros, 2008). Rather than focusing on a problem, this model encourages a focus on what is working well and what the organization does well, and then broadens and builds on the strengths. This model is predicated on the belief that when we expand what we do best, problems seem to fall away or are outgrown. Leading through positive interactions results in people working together toward a shared vision and preferred future without the burden of being weighed down by problems. Leaders using this leadership model are open to inquiry without having a preconceived outcome in mind; rather, they facilitate a search for shared meaning and build and expand on what is working well. For example, faculty in an APRN graduate program wanted to create a DNP program, but there were quality concerns about some of their existing Master of Science in Nursing options. Through an AI process, the faculty decided to build a DNP program based solely on the certified registered nurse anesthetist (CRNA) role because that was their strongest offering at the time. Moreover, through this process they decided to phase out two of their Master of Science in Nursing options because they were not up to the same level of quality. Over time, the CRNA program was recognized as one of the nation's top programs. So, rather than investing solely in “fixing what's broken,” the AI model directs resources and visioning to an organization's greatest strengths. This leadership model uses a 4D cycle: • Discovery—an exploration of what is; finding organizational strengths and processes that work well • Dream—imagining what could be; envisioning innovations that would work even better for the organization's future • Design—determining what should be; planning and prioritizing those processes • Destiny—creating what should be; implementing the design AI uses a positive perspective that can be motivational and inspirational for employees with the goal of increasing exceptional performance. This model can work well for APRNs who are skilled in developing partnerships. Although evidence for the effectiveness of this leadership model is limited, there is enough evidence to support further rigorous research (Jones, 2010). The consequences of leading with an emphasis on defects are that the process lacks vision, places attention on yesterday's causes, and can lead to narrow and fragmented solutions. The AI model shifts from asking “What is the biggest problem?” to “What possibilities exist that we have not yet considered?” This approach quickly leads individuals to a shared purpose and vision. Concepts Related to Change Change refers to the various types of initiatives aimed at improving the quality and safety of practice, whether by revising policies or helping clinicians master new knowledge and change behavior. In other words, change is seen as any clinical or systems effort to encourage the adoption and diffusion of innovation, including quality improvement, product rollouts, clinician education, and skill development. Change is viewed as a process so that it does not have a discrete beginning and end but, instead, appears to be a series of continuous transitions that overlap one another. This means that the ability to bring about change must be woven into the fabric of the everyday life and work of APRNs. As with patient assessment to effect individual behavior change, APRNs must be skilled at assessing and reassessing their organizations and the complex forces that drive the health care system to be effective change agents. Systems innovation requires leadership that is continuous and flexible and demands ongoing attention to and redefinition of appropriate strategies (Greenhalgh et al., 2004; Klein, Gabelnick, & Herr, 1998; Kwamie, 2015; Massoud et al., 2006; Shirey, 2015; Thompson & Nelson-Martin, 2011). Opinion Leadership One way that change can be initiated is through the use of opinion leadership (Anderson & Titler, 2014). Opinion leaders are clinicians who are identified by their colleagues as likeable, trustworthy, and influential (Flodgren et al., 2007). Clinicians are likely to listen to the opinion leader and make a change in practice based on what has been learned from the opinion leader. One study of opinion leaders in several different clinical settings has indicated that contextual factors influence the ability of an opinion leader to promote guideline adoption by colleagues (Locock, Dopson, Chambers, & Gabbay, 2001). Shirey (2008) pointed out that there are several elements of being the opinion leader, including being knowledgeable, respected, trusted, and well connected within the organization; in addition, opinion leaders must also be generous with their time and advice. APRNs become opinion leaders as they are recognized for their astute clinical decision making and influence of others. They are sought out by others and, when APRN opinion leaders speak, others listen. Thus a staff nurse may ask a CNS wound care specialist to examine a wound and provide treatment advice. Colleagues are eager to try the new information when an NP returns from a conference and shares what was learned. CRNAs are consulted for their opinion on airway management. These examples suggest the importance of attending to environmental cues when change is planned. Unfortunately, there is very limited evidence on the effectiveness of opinion leaders concerning change. This may be because there have been few studies of this model of leadership. Driving and Restraining Forces Driving and restraining forces are useful concepts for APRNs planning for change, including managing the intended and unintended consequences of change. For example, the movement toward multistate licensure has gained momentum as APRNs extend their practices across state lines (Young et al., 2012; see Chapter 12, Fig. 12.1, for an illustration of driving and restraining forces). These forces can serve as driving or restraining influences for APRNs depending on different policies and procedures for reimbursement and prescriptive authority within states. As multistate licensure for APRNs evolves, telehealth may be considered a driving force and states' rights may be a restraining force. For example, a psychiatric/mental health NP in one state may wish to use telehealth methods to treat patients in an adjoining state to save patients the time and expense of driving to therapy sessions. The states allow for this under the RN license but do not allow for this under the APRN approval. The APRN would have to seek and obtain recognition from the board of nursing in the state where the patient is located. There may be very different rules in the two states about physician collaboration or supervision, scope of practice, and prescription rules, and these could be a restraining force for extending this practice. The unintended consequence of these rules and regulations could be to restrict care by APRNs to rural residents. Understanding driving and restraining forces helps in analyzing the organizational settings in which APRNs work. For example, an organizational assessment of these various forces is useful in determining an institution's level of commitment to diversity. At times, physicians have been both driving and restraining forces for change. Experienced APRNs know that one of the challenges in system redesign and transformation has been engaging physicians in the work of improving quality as a team member. Berwick (2016) has argued that there is now a new era in health care that calls for an end to the protectionism seen earlier. He points out that better care, better health, and lower costs can be brought about by working with others to improve care in a transparent way. APRNs and physicians are players who can lead together to offset professional prerogative and greed while listening to the voices of the people served. Pace of Change A major concern is the rapidity with which change occurs in the health care industry. Even when one develops detailed plans for a change, events may occur that reshape the process and progress so that what gets implemented may not be the same as the original proposal. As the rapidity of change increases, the time frame to accomplish change strategies shortens. This phenomenon makes change more difficult for individuals and organizations to manage. As a consequence, many of the traditional models still being used to implement change will not be successful. Planned versus unplanned change is based predominantly on issues of time—time to plan for and think through the desired change, time to orient and allow stakeholders to become comfortable with the proposed change, and time to educate and allow the change process to occur. Many required changes in health care do not have sufficient time to allow the proposed change to naturally evolve. Transitional leadership may offer the best hope for survival in rapid change situations. Whether health care organizations can sustain fast-paced change is not clear unless there is a commitment to the culture of change. This commitment assists and supports adaptation to new systems and ways of knowing and doing. A culture of change requires several components, including learning about change and change strategies, encouraging dialogue, valuing collaboration and differences, and being committed to enacting change. In a classic work, O'Connell (1999) proposed strategies for promoting a culture of change within an organization (Box 11.2). Box 11.2 O'Connell's Strategies That Promote a Culture of Change • Maintain momentum toward change. • Emphasize managerial support in the process of changing workflow and practice patterns. • Encourage the question “why” and exercise tolerance for the results. • Emphasize the importance of personal concerns and address them. • Find new and different ways to demonstrate administrative support. Adapted from O'Connell, C. (1999). A culture of change or a change of culture. Nursing Administration Quarterly, 23, 65–68. APRNs can use one or more of the models of leadership described here to assess their systems. Knowing where one's system is in terms of readiness for change and identifying the forces that will support or restrain adoption of an innovation can help the APRN design strategies that will work. It is also helpful to consider the techniques used for implementing change, such as building alliances, creating a shared vision, being assertive, negotiating conflict, and managing transitions as they relate to providing a positive culture for change. As leaders, APRNs can use their skills to translate the need for and perspectives on change among clinicians, patients, families, and administrators. In addition, APRN leaders need to be prepared to identify when it is not in an organization's best interest to pursue a change based on context, environment, inadequate problem solving, or unresolved barriers. Repetitive, rapid change can take a toll on engagement and productivity and potentially on patient safety, particularly if implications and consequences are not thoroughly considered. Most importantly, leaders need to understand the personal implications of change if a culture of change is to be realized. Box 11.3 provides a useful set of strategies for APRN leaders who are helping their organizations and colleagues work through change transitions. Box 11.3 Leadership Strategies for Moving Through Change • Spark a passion; believe in what you are doing; shine a light on activities that inspire and excite. • Understand the organizational culture. • Create a vision. • Get the right people involved. • Hand the work over to the champions of change. • Let values serve as the compass for where you are headed. • Change people first; organizations evolve. • Seek and provide opportunities for professional renewal and regeneration. • Maintain a healthy balance. Adapted from Kerfoot, K., & Chaffee, M. W. (2007). Ten keys to unlock policy change in the workplace. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (pp. 482–484). Philadelphia: Saunders; and Kerfoot, K. (2005). On leadership: Building confident organizations by filling buckets, building infrastructures, and shining the flashlight. Dermatology Nursing, 17, 154–156. Types of Leadership for APRNs Some APRNs are not comfortable with the idea of being leaders. This may be because they see leadership as outside of their goal of caring for their patients. However, upon a more careful view, leadership is understood to be necessary to bring about the kinds of things that ensure good patient care. APRN leadership competency can be conceptualized as occurring in four primary areas: in clinical practice with patients and staff, within professional organizations, within health care systems, and in health policymaking arenas. The extent to which individual APRNs choose to lead in each of these areas depends on patients' needs; personal characteristics, interests, and commitments of the APRN; institutional or organizational priorities and opportunities; and priority health policy issues in nursing as a whole and within one's specialty. These four areas have substantial overlap. For example, developing clinical leadership skills will enable the APRN to be more effective at the policy level as clinical expertise informs policymaking. Clinical Leadership Clinical leadership focuses on the needs and goals of the patient and family and ensures that quality patient care is achieved. Clinical leadership is a foundational component to attaining and maintaining a productive environment in which safe and excellent care employing best practices is provided (Murphy, Quillinan, & Carolan, 2009). This leadership occurs when APRNs acquire and apply knowledge about how to build appropriate working relationships with health care team members, how to instill confidence in patients and colleagues, and how to problem-solve as part of a team (Bally, 2007). APRN leaders propose and implement change strategies that improve patient care. Some clinical leadership skills are part of the competencies of consultation (see Chapter 9) and collaboration (see Chapter 12). The most common clinical leadership roles APRNs fulfill are those of advocate (for patient, family, staff, or colleagues), group leader, and systems leader. APRNs may advocate for a particular patient or family, as when an acute care nurse practitioner (ACNP) discusses with the attending surgeon the need for the patient to have a clear understanding of the potential adverse effects of an elective surgery. The surgeon may have concluded that the patient and family fully understood the potential outcomes of the surgery but the ACNP discovered that there was broad misunderstanding by the patient and family. Presenting talks or writing articles on clinical topics are other ways of expressing clinical leadership and influencing others. The important aspect of clinical leadership is that the APRN steps up, assuring the best clinical outcome for any particular patient. Group leadership may be informal, as when an APRN agrees to coordinate multiple referrals for a patient with complex care needs or has expertise in a particular clinical problem such as pain management, skin care, or screening for cervical cancer and assumes a team leadership role reflecting this expertise. APRNs may also have more formal leadership responsibilities; for example, an APRN may lead a weekly team meeting or agree to convene a group and lead the development of a new practice protocol to bring care into line with newly released standards of care. One function of the APRN leader is to motivate colleagues and facilitate their use of new knowledge and/or the adoption of new practices with the goal of improved patient outcomes. APRNs often exercise leadership to ensure that clinical problems are addressed by administrative leaders at a systems level. This type of leadership requires that APRNs move between the clinical and administrative arenas, interpreting the needs of one to the other. Advancing clinical excellence requires financial, creative, and political skills to promote innovative care with others (Murphy et al., 2009). Having these additional skills improves the success of this form of clinical leadership and the compelling translation of ideas between distinct, sometimes competing perspectives. APRNs recognize the clinical problems related to their specialty that require attention or intervention from the larger (macro) system of which they are a part. For example, when a CNS called a patient to learn why he had not kept his appointment at the heart failure clinic, she learned that the patient could not find parking nearby because of hospital construction, did not know that a shuttle would take him from the satellite lot to the clinic, and did not have the energy to walk from the satellite lot. The CNS knew that this could be a problem for other clinic patients and worked with administrators to make sure patients had knowledge of and access to the resources that were needed and available. The CNS understood the clinical implications (patients might experience more complications requiring readmission) and systems implications (e.g., lower care quality, increased risks for patients, higher costs, missed appointments) of construction-related missed appointments for her patient population. APRNs who lead patient care teams effectively find that their interprofessional leadership skills are in demand. For example, an APRN who was successful in leading a quality improvement initiative to improve care of patients with asthma who were admitted to the hospital was invited to chair a national task force of health care professionals developing practice guidelines for the treatment of asthma. The ability to provide clinical interprofessional leadership requires a firm grasp of clinical and professional issues while responding to the challenges of other disciplines and the larger society. It necessitates a deep respect for other clinicians and the creation of a safe and welcoming place for all voices to be heard. APRNs develop the attributes needed to lead in other domains as they build on a solid foundation of strong clinical leadership. Professional Leadership Active participation and leadership are particularly important and exercised in professional organizations. Novice APRNs may begin by seeking membership on a committee of a local, state, or national nursing or interprofessional organization. These organizations are built on the voluntary contributions of their members and rely on members to achieve the organization's goals. As APRNs become more experienced, they may seek opportunities to apply the leadership skills that they have learned in their work to their professional organizations. Most APRNs are members of one or more nursing and interprofessional organizations. These memberships provide a myriad of leadership opportunities, including organizing continuing education offerings, presenting at national conferences, chairing a committee, and running for the board of directors. In these situations, APRNs exercise more choice as to whether and when they will participate in leadership activities than they do in their usual work roles. Professional leadership often begins locally and proceeds to state, national, and international levels. Novice APRNs can acquire leadership skills and experience by becoming involved in the leadership and committee work of local advanced practice nursing coalitions and organizations and progressing into state and regional leadership roles as they develop their style, strengths, and network as APRN leaders. The ability to place APRN leaders in key local, state, and national positions is critical to the visibility and credibility of APRNs and to the establishment of their place within nursing and the larger health care community. In addition to informal leadership development opportunities, there are also formal programs in which APRNs can develop the skills to lead in positions such as board membership (Carlson et al., 2011). Systems Leadership Systems leadership means leading at the organizational or delivery system level—a skill that requires a multidimensional understanding of systems. Systems leadership often requires a “big picture” view and understanding elements in care delivery far beyond nursing. Within health care organizations, APRNs may lead clinical teams, chair committees, chair or serve as members of boards, manage projects, and direct other initiatives aimed at improving patient care as well as the clinical practice of nurses and other professionals. Systems leadership overlaps professional situations in which leaders are elected or appointed to positions within defined organizations and groups. For example, APRNs may identify an increase in the rate of patient falls and lead a task force to evaluate the problem and design corrective interventions. A critical care CNS or ACNP may initiate interprofessional rounds to monitor patients on mechanical ventilation and gather data on clinical variables such as complication rate and time to weaning. APRNs may be asked to participate in or lead standing or ad hoc interprofessional committees such as credentialing, ethics, institutional review board, or pharmacy and therapeutics committees. APRNs may be asked by administrators to participate in organizational reengineering or other activities aimed at improving the environment in which others practice. APRNs need to be aware that the characteristics of successful entrepreneurs are desirable and valued in systems leaders. The term entrepreneurial leadership refers to leaders who go outside of traditional employment systems to create new opportunities to exercise their unique abilities (Shirey, 2004). When these leaders use the entrepreneurial skills of innovation and risk taking and assume responsibility for achieving specific targets in an organization, they are termed intrapreneurs. Because this leadership style is consistent with the call for health care system redesign, it is worth reviewing characteristics associated with entrepreneurial leadership. Shirey (2007b) has stated that nurse entrepreneurs have a desire to make a difference and see opportunities in situations in which others see barriers or challenges. Blanchard, Hutson, and Willis (2007) have developed tools for leaders to assess their entrepreneurial strengths and have identified attributes of entrepreneurs, including being resourceful, purposeful, a risk taker, a problem solver, innovative, communicative, and determined. Universities that prepare APRNs are offering coursework on innovation, entrepreneurship, and innovative thinking to prepare entrepreneurial and intrapreneurial APRN leaders (Shirey, 2007a). APRNs frequently underestimate their transferable skills, which can be used in entrepreneurial or intrapreneurial opportunities (Shirey, 2009). Recognition of these skills will assist intrapreneurial APRNs to build a case for how their services can assist the organization in achieving innovative clinical excellence (Shirey, 2007b). Entrepreneurial leadership skills are illustrated in Exemplar 11.1, which also illustrates the evolving nature of advanced practice nursing leadership and how it can expand in breadth over time to lead national and international policy. Dr. Bednash moved from staff nurse to NP to leader of one of the premier national organizations in nursing education. She credits her NP education with providing her the basis for her international leadership. Exemplar 11.1 APRN Leadership in Action Geraldine (Polly) Bednash, PhD, RN, FAAN, Nurse Practitioner Dr. Geraldine “Polly” Bednash attributes much of her rise to national and international leadership to her preparation as a nurse practitioner. Her childhood was spent in San Antonio, Texas, which was primarily a small military town at the time with strong Latin American roots. She fondly recalls making tamales with family and going to market with her grandmother to acquire the needed ingredients to help treat family illnesses. She did not grow up with the idea of becoming a nurse but selected this when she entered university. Money was tight so she worked throughout her time in school. She enrolled in the Army Nurse Corps for the last 2 years of school and immediately entered service after graduation. She met her husband while serving as a Nurse Corp officer in Vietnam. She and her husband moved to New York after her Army service, and she assumed a position as a faculty member at a diploma nursing school in the New York area. Later, her husband's company moved them to the Washington, DC, area, but there she quickly discovered that her baccalaureate degree would not garner her a faculty position. She obtained her master's degree in medical-surgical nursing at Catholic University and again assumed a faculty position in nursing education. She was accepted into the Robert Wood Johnson Foundation program to prepare nursing faculty to become nurse practitioners. She describes becoming a nurse practitioner in the early 1980s as “eye opening” and “ground breaking.” In this new role she was expected to be a risk taker, to be on top of her game, and to have good working relationships with physicians and other health care professionals. She credits this education with forming the foundation for much of her future success as a national and international leader in nursing. Nurse practitioners diagnosed and treated patients but also considered the cultural and economic issues related to their care. As an independent practitioner she was required to understand the needs of the individual within the context of the larger system. This was not a part of traditional hospital nursing practice at the time. She went on to complete her PhD at the University of Maryland and transitioned her career to policy leadership. For 3 years, Dr. Bednash was Director of Government Affairs of the American Association of Colleges of Nursing (AACN), and she was then selected to be Executive Director. She led that organization through its dramatic evolution as one of the nation's most important voices for nursing education, practice, and research. Her leadership at the AACN is credited with establishing the Association as the national voice for baccalaureate and graduate nursing education. Dr. Bednash was the driving force behind expanding the AACN's reach and influence in all health care and higher education circles as well as in the US Congress and with the Administration. She mobilized support for the AACN's signature initiatives, including the creation and ongoing revision of the Essentials documents, the establishment of the Commission on Collegiate Nursing Education, the advancement of the practice doctorate, and the development of the clinical nurse leader role and the Commission on Nurse Certification. In addition, Dr. Bednash spearheaded dozens of grant-funded initiatives, including the Endof-Life Nursing Consortium and the New Careers in Nursing Program. Like many leaders, Dr. Bednash credits a number of individuals who helped her along the way. These include internationally renowned leaders in nursing and health care who provided support, words of wisdom, and encouragement at important times in her life. For example, when a patient experienced an adverse effect from a medication Dr. Bednash had prescribed, it was a physician colleague who helped her to understand that sometimes the work of nurse practitioners may place patients in harm's way and that she must learn from this event to help other patients. She has devoted a good deal of her leadership experience to mentoring, coaching, and assisting others who aspire to leadership. The unique nature of her work as the head of a nursing organization that served many nursing schools meant that she had to be judicious in the selection of individuals to assist. Most of the people for whom she has served as a mentor are in professions other than nursing. Her suggestions for advance practice registered nurses (APRNs) who are building competence in leadership is to always be open to the advice of those around you, even if you are not sure at the time you want to hear that advice. She also encourages APRNs to cultivate colleagues who will tell it like it is rather than rapidly agreeing with your position. And, always strive for transparency in your leadership work. Willingness to Name Difficult Organizational Problems A common human characteristic in organizations is to operate around the periphery of problems and not in the heart of them. Rare is the leader who directly acknowledges and names dysfunctional activities that are deeply embedded in organizations. A key role of APRNs is to name the problem without implying blame. This approach to leadership brings a problem into the light without the burden of having to solve it. In this way, the APRN is inviting others into the conversation for a better understanding of barriers to collaborative practice and state-of-the-art, patient-centered care. For example, if office staff think that they do not have the authority to make scheduling and patient flow work better, the APRN can name this problem and invite members of the organization to explore it further. The willingness for APRNs to enter into these courageous conversations is a key skill set to effective collaboration. When there are high-stakes issues with high emotions, it is tempting to focus instead on peripheral issues. In another example, a primary care practice had for some time had a significant number of patient and staff complaints about waiting times to see a physician who was excellent but slow. She was always behind in her appointment times and could not keep pace with the demands of primary care. This created conflict in the waiting room and with support staff as patients frequently waited more than 2 hours to be seen for a scheduled appointment. Sometimes patients left without being treated after they had been checked in. The APRN who recently joined the practice was able to name the problem and the impact on the entire system, including paying overtime for medical assistants to work late. This naming of a problem that had been going on for years greatly relieved the organization. Once the problem and its dimensions were defined, the physician became aware of the impact that these long waits had on the entire office, as well as on her patients. The team came up with an approach that allowed this particular physician to have longer appointments and booked some vacant slots to allow for catch up. The manner in which the APRN raised the quality concerns made it safe because it was always in the context of patient care. APRNs can enter these conversations by naming troubling dynamics or environmental threats. A patient's problem cannot be resolved without having its dimensions clearly defined. The same holds true for organizational leadership and the need to foster more collaboration and unity at the systems level. This type of acknowledgment of issues and willingness to name problems without having to solve them is a powerful way for APRNs to model true leadership. Health Policy Leadership Some APRNs may not see themselves as being particularly interested in or talented at political advocacy. However, all APRNs have a vested interest in policymaking that affects their patients' care, health care funding, national priorities in health, and state and local policies related to the health of the community they serve. Understanding and leading in health policy has become increasingly important as more laws and regulations are enacted with implications for APRN practice (see Chapters 19 and 22). APRNs should be aware of and must often respond to local, state, and national policymaking efforts likely to affect these laws and regulations. Organizations that define competencies for APRNs also have competencies related to health policy. Leadership in health policy requires an ability to analyze health care systems, an understanding of the personal qualities associated with effective leadership, and the skill to use this knowledge strategically. Across these four domains of leadership, APRNs use their clinical expertise, team building, and collaborative skills to build community around shared values such as patient-centeredness and commitment to quality. To exert leadership in health policy, APRNs will be expected to remain informed about current and emerging issues in health care such as changes in federal and state regulations concerning scope of practice and nursing education funding proposals. APRNs are expected to understand the broad elements of government so that there can be timely and effective contact with policymakers to ensure that the APRNs' patients will be well represented in any proposed changes in laws or regulation. The APRN may not passively allow changes to happen but is expected to actively participate in discussion and actions for policy change. This policy work can combine leadership in clinical care, professional activities, and systems leadership. The defining characteristics of APRN leadership—mentoring, innovation, change agency, and activism—may be apparent in all four domains, but the emphasis accorded to each one depends on the particular leadership demands. Characteristics of APRN Leadership Competency The three defining characteristics of APRN leadership—mentoring, empowering others, and innovation—are listed, along with their core elements, in Table 11.2. These are discussed separately here to assist in understanding the differences among them. However, there is considerable overlap in the knowledge and skills needed for each characteristic. Experienced APRNs can demonstrate these characteristics in all four domains of leadership. APRNs often focus on developing clinical leadership first because the new clinical work can be time consuming. As APRNs gain more confidence in their advanced clinical abilities, they tend to expand their leadership in additional domains such as mentoring and empowering others. TABLE 11.2 Mentoring A key element of APRN leadership competency is mentoring others. The ability to help others grow and encourage them toward developing their full potential requires competent, caring leaders who are interested in the success and well-being of others. Mentoring also ensures the development of future nurse leaders (McCloughen, O'Brien, & Jackson, 2010). Mentoring bridges the gap between professional education and the experiences of the subsequent working world (Barker, 2006). Guiding and coaching, leading by example, and role modeling with awareness and attentiveness to the needs and concerns of followers are basic characteristics of successful leaders. The ideas behind the colloquial statements of “taking someone under your wing” or “giving a colleague a leg up” are grounded in the mentoring process. Mentors are competent and self-confident, having qualities that epitomize success in their own careers and having the ability and desire to help others succeed. Other characteristics of successful mentors include inspiring, confident, committed to the development of others, and being willing to share. Mentors take on responsibility for the development of protégé skills, such as flexibility, adaptability, judgment, and creativity (McCloughen et al., 2010). Protégés are viewed as individuals who express a desire to learn, are committed to the long course of events, and are open to the process of trial and error. Successful protégés have high self-esteem, can selfmonitor, and are resilient risk takers (Tourigny & Pulich, 2005). The reward for the mentor is to step back and enjoy the success and achievements of the protégé. APRNs who have had the benefit of mentoring report that it affected the progression of their career and enriched their leadership development (McCloughen, O'Brien, & Jackson, 2009). Two types of mentoring are described in the literature. The first, termed formal mentoring, has the approval and support of an organization with objectives, a selection process, and a mentoring contract. Mentors are chosen from the ranks of experienced clinicians and provide exposure to clinical situations that offer opportunities to demonstrate competence, coaching, and role modeling and afford protection in controversial situations (Tourigny & Pulich, 2005). Many professional organizations, such as Sigma Theta Tau International and the National Organization of Nurse Practitioner Faculties, offer formal mentoring programs, and information is usually available on the organizations' websites. The term informal mentoring is a relationship that is unstructured and mutually beneficial; the experiences usually last longer and are self-selected (Tourigny & Pulich, 2005). Good mentors foster growth rather than dependency and instill the internal strengths to enable protégés to traverse rough spots in their career development. Mentors lead protégés on a journey of self-discovery and help them find the value they bring to the role and to nursing leadership (Vos, 2009). As mentoring relationships progress, the protégé takes on more freedom to try new behaviors and develops confidence in trying new skills, always with the knowledge that someone is behind him or her. Mentoring relationships can be developed based on specific needs of the APRN protégé, such as writing for publication or developing professional presentation skills, or on the general development of career and leadership skills. Harrington (2011) has reported that mentoring new NPs will accelerate their development as primary care providers. Finding a mentor in one's geographic location may not be feasible, depending on the skill to be developed. In today's technological world, however, APRN leaders can establish mentoring relationships at a distance that can be a rewarding experience as well. Use of conference calls, videoconferencing, social media, and networking at professional conferences can all be feasible means to support a distance mentoring relationship. There are two parts to the APRN mentorship equation: APRNs who are seeking to be mentored by those they aspire to emulate and APRNs who can serve as mentors. Some APRN leaders are reluctant to serve as a mentor for a variety of reasons. However, Vance (2002) has asserted that a chaotic health care environment makes mentoring support more important than ever. She suggested that mentors and protégés adopt a mentoring philosophy that encourages collaboration with others, not competition. Novice APRNs are fortunate if they can find a mentoring relationship that lasts over time. The APRN mentor creates a safety net in which the protégé can expose vulnerabilities and be coached to develop confidence in new skills. Mentoring is a gift that allows new APRN leaders to emerge. Today, APRNs taking on large leadership roles engage executive coaches, and more often paid executive coaches. There is a cadre of nurses who do executive coaching, and these relationships can be highly valuable because the mentor is safely outside of the organization. APRNs who take on new executive leadership positions can negotiate in their employment package for the organization to pay for executive coaching. An interrelationship exists among the concepts of mentoring, organizational culture, and leadership. Watkins (2013) described organizational culture as the patterns of behavior of an organization, and these patterns are dynamic, changing over time. A positive organizational culture offers social support and a sense of well-being and empowerment that fosters the mentoring process (Harrington, 2011). Thus APRNs should seek opportunities to mentor or be mentored and articulate the benefits of mentoring activities to their organization. Empowering Others The term empowerment is best understood as giving power to others, and this is often done by encouraging others and giving them authority. APRNs operationalize empowerment by sharing power with others, including patients, as well as by enabling them to access or assert their own power. Empowerment as a leadership strategy is guided by the shared vision of the leader and follower and a willingness of the leader to delegate authority to others. Leaders who empower their followers greatly increase the influence of APRNs within nursing and beyond nursing's boundaries. In some ways, empowerment shares some characteristics with mentoring. There is a continuously developing reciprocal relationship between the two key players. Empowerment requires more than just giving others permission to act on their own. It is a developmental process that a good leader fosters over time; it encourages constituents to feel competent, responsible, independent, and authorized to act. Quast (2011) provided six ways to empower others to succeed (Box 11.4). Box 11.4 Six Ways to Empower Others to Succeed • Share information. • Create clear goals and objectives. • Teach that it is OK to make mistakes. • Create an environment that celebrates both successes and failures. • Support a learning environment. • Let teams become the hierarchy. Courtesy of Lisa Quast. Adapted from Quast, L. (2011). 6 ways to empower others to succeed. Forbes. Retrieved from http://www.forbes.com/sites/lisaquast/2011/02/28/6-waysto-empower-others-to-succeed/#18b792493cc8. For example, certified nurse-midwifes (CNMs) empower pregnant women by putting them in control of the birthing process through education, mentoring, and providing resources for parenting that nurture self-esteem and enhance family structure. CNMs are quick to let others know that they do not deliver babies—mothers deliver babies and midwives assist. This changes the power gradient in such a way that the mother is no longer dependent or passive in the birthing process. Instead, she is the decision maker and in control. This is very different from the paternalistic and hierarchical relationships seen in many obstetric medical practices. Innovation As the prior discussion suggests, initiating and sustaining innovation are critical elements of the APRN leadership competency. Covey's work (1989) with interprofessional groups is instructive to APRNs who are learning innovation skills. Innovation requires the capacity of the person to envision a world that can be and not just a world that is. This can be difficult for some because such a vision requires stepping over boundaries, cultures, politics, personal likes, and other elements that we hold very closely. Change occurs at the system and personal levels, and one must deal with core values to change or to serve as an agent for change successfully. Covey contended that people have a changeless core inside them that they need if they themselves are to be able to change. Thus one key to the ability of people to change is a strong sense of who they are and what they value. Lasting change comes from the inside out. This observation is relevant to APRNs. First, APRNs need to identify their own core values to become effective in leading change. Second, Covey's insight can help APRNs who encounter resistance to change initiatives, especially when it persists. The resistance may come from the sense that a core value is being threatened. There is an affective dimension to change. Although many people express an excitement at the prospect of change, some changes are difficult and painful, and any change contains an element of loss. Mastering emotional tension during change requires perseverance, patience, and compassion. At best, change can be described as challenging and invigorating. Lazarus and Fell (2011) have suggested that it is important to close the gap in creativity and use innovation as a process to induce change in health care. To understand change in today's health care environment, APRNs must explore the dynamics of change and the culture in which it occurs. APRNs generally consider several factors when they are proposing an innovation—the relevance of power and influence, stakeholders' concerns and interests, contextual factors, individuals' values, and the affective dimensions of change. Understanding these important factors is integral to the APRN leadership competency. Political Activism Political activism and advocacy will become even more important as APRNs hone their skills for systems leadership and change. Many of the skills needed to navigate successfully in political waters are closely associated with good leadership. The core elements that define contemporary leadership, such as shared vision, systems thinking, and the ability to engage in high-level communication within the context of a changing environment, are all basic to political effectiveness. Again, change leading to care improvement is the common element that drives APRNs to advocate for advanced practice and patient issues. There is little room for discussion about whether APRNs need to take on the mantles of policymaker and patient advocate as part of their leadership role (see Chapter 19). For many, this falls within the context of a moral imperative: “Nurses practice at the intersection of public policy and the personal lives (of their patients); they are, therefore, ideally situated and morally obligated to include sociopolitical advocacy in their practice” (FalkRafael, 2005, p. 222). Working for social justice is seen as part of the ethical decision-making competency of APRNs (see Chapter 13). APRNs must position themselves strategically at the policy table to advocate for access to care and appropriate interventions for everyone. Great strides have been made in developing nurses' skill and acuity as policymakers (see Chapter 19). Rapidly evolving policy situations mean that APRNs are often faced with trial-by-fire learning when it comes to activism and advocacy. However, policy issues tend to wax and wane so that APRNs do not always have to be highly engaged and can at times monitor the situation. Identifying trusted mentors with whom to debrief and developing a plan of action can help APRNs develop the poise and skills needed to respond effectively in unexpected, chaotic, and tense political situations. Although activism is frequently associated with advocacy in the political realm, activism can occur in the clinical and system environments as well. The same leadership skills apply in those settings when advocating for issues such as access to care, ethical decision making, and resolving injustice. Attributes of Effective APRN Leaders Several personal attributes are deemed necessary for successful leadership (Box 11.5). Effective leaders demonstrate these broad qualities because they are needed in the interprofessional context of today's health care. Nurses are called to exert their leadership expertise far beyond nursing circles. The history of advanced practice registered nursing (see Chapter 1) demonstrates that nurse leaders have always led outside the realm of organized nursing education and practice. Box 11.5 Attributes of APRN Leaders Expert Communication Skills • Articulate in speech and in writing • Able to get own point across • Uses excellent listening skills • Desires to hear and understand another's point of view • Stays connected to other people Commitment • Gives of self personally and professionally • Listens to own inner voice • Balances professional and private life • Plans ahead; makes change happen • Engages in self-reflection Developing One's Own Style • Gets and stays involved • Sets priorities • Manages boundaries • Uses technology • Engages in lifelong learning • Maintains a good sense of humor Risk Taking • Gets involved at any level • Demonstrates self-confidence and assertiveness • Uses creative and big picture thinking • Willing to fail and begin again • Has an astute sense of timing • Copes with change Willingness to Collaborate • Respects cultural diversity • Desires to build teams and alliances • Shares power • Willing to mentor Adapted from Hanson, C., Boyle, J., Hatmaker, D., & Murray, J. (1999). Finding your voice as a leader. Washington DC: American Academy of Nursing. Timing A good sense of timing may come easily to some, but for most people it requires painstaking development and practice. APRN leaders know when to act and when to hold back. They recognize the need for urgency at times as, for example, during an unexpected legislative vote in Congress; they also know to take the time to develop a carefully thought-out plan with deliberate strategy when a change in scope of practice is being considered. The notion of timing is apparent when APRNs use mandated change as an opportunity to introduce other changes. For example, institutions applying for accreditation by The Joint Commission (TJC) are expected to demonstrate compliance with TJC's current evidence-based standards for specific health care problems (TJC, 2016). Many institutions use these mandated changes to launch a variety of initiatives aimed at improving care management. An example of timing took place during a legislative session in Tennessee. APRNs were seeking to have a joint Senate and House committee remove regulations that restricted NP practices to limited locations. During the committee meetings, an NP testified about the many challenges the restrictive language imposed on NPs in providing good care in rural and underserved communities. The chairman of the committee stated that, if the NPs were “unshackled” from their communities, they would leave and that the existing rules kept the NP tied to the community. Clearly, this language offended nurses, patients, and communities, but this committee meeting was not the time to call the chairman out. Following the committee hearing, the press got wind of the statement with the help of some very astute nurses in the audience, and the public outrage over these insensitive comments was explosive. The news media reported that the chairman, who happened to be African American, should have recognized the inappropriateness of his statements, particularly in a former southern slave state. The chairman subsequently met with the NP who testified before the committee, apologized for the language, and sponsored a new bill to revoke the restrictive language during the next session. The timing of the release of the chairman's comments by the media made all the difference in this situation. Self-Confidence and Risk Taking Taking risks is inherent in the leadership process and is tied inextricably to self-confidence. The willingness to take a chance, try, and occasionally fail is the mark of a true leader. Risk-taking behaviors differentiate APRNs who will be recognized as leaders and change drivers from other capable nurses. By learning to take risks, APRNs enhance their leadership repertoire, allowing for more spontaneity and flexibility in response to conflict, resistance, anger, and other reactions to change and high-risk situations. Motivation is the desire to move forward and can also be viewed as a component of risk taking. Wheatley (2005) has affirmed that another component of risk taking is the willingness to be disturbed. Certainty is more comfortable. Staying put is rarely as risky as taking the chance to move ahead. Risk taking should be differentiated from risky leadership behaviors. Taking good risks involves evaluating all types of evidence available at the time and making educated decisions based on that information. It also involves trying to anticipate consequences of actions, having a plan in place to evaluate the implementation, being willing to accept that the risk was not successful, and learning from the experience. Risky behavior, on the other hand, involves making decisions impulsively without fully exploring available information or having a strategy to address unintended consequences. Several of the key attributes in Box 11.5 incorporate some form of the word willingness. The abilities to be open, to learn, to change one's mind, to be willing to take what comes, and to work through differences are key to all levels of leadership. Leadership is about negotiation and interactions with others to reach common goals. To do this may mean failing and trying again and again to reach the desired outcome. This quality of personal hardiness—the ability to pick oneself up and start again—is seen repeatedly in biographies of successful leaders who have made change happen in difficult times. Communication and Relationship Building The relevance of communication skills and collegial relationships to quality health care has received attention (Castledine, 2008). APRNs who lead must be able to communicate effectively with others (see Chapter 12) and participate in the identification and resolution of clinical and ethical conflicts among team members (see Chapter 13). The successful leader must have the requisite communication skills to build the trust and cooperation necessary to negotiate difficult intraprofessional and interprofessional issues. The ability to understand another's viewpoint and respect opposing views is key to effective communication and ultimately to reaching a mutually satisfactory outcome. Covey (1989) has suggested that leaders will need to understand and be understood by others. Good leaders listen and understand the other person's viewpoint before they speak. The charisma that is associated with many leaders is often simply outstanding listening and communication skills. The ability to influence a key power strategy used to gain the cooperation of others is an outcome of excellent communication. A second part of expert communication is relationship building. The art of building strong alliances and coalitions with others and staying connected with colleagues and groups is basic to the sense of community needed to lead effectively. Building relationships within the work environment can minimize the impact of organizational structures that hinder one's ability to collaborate and solve problems (Wheatley, 2005). These alliances are important, whether at the highest levels of international policymaking or at the local level when building a coalition to address a recurring patient issue. Building relationships is central to the effectiveness of a team who cares for patients. Not only must APRNs establish effective relationships with their coworkers, but they are often in a position to strengthen relationships among other members of the team through role modeling and mediation. Thought leaders use conversational leadership as a way to bring key groups together to raise critical questions and issues and gain collective intelligence leading to innovation and wise actions. Open conversations are one way in which leaders share what they know with colleagues and create new ways of knowing and doing. This type of open conversation may lead to having the courageous conversations that are sometimes needed to name a problem so that the communication can move forward. Building relationships is also central to another APRN communication skill, conflict negotiation (see Chapter 12). APRN students may come to their educational programs having been socialized to be silent or suppress their opinion in situations of conflict. Specific approaches to identifying conflicts and resolving them successfully have been identified and used successfully in business (Fisher, Ury, & Patton, 2011) and in health care (Longo & Sherman, 2007). The website for the Conflict Resolution Network (www.crnhq.org) is a resource on conflict negotiation. Boundary Management: Balancing Professional and Personal Life Managing boundaries refers to how APRNs deal with various aspects of advanced practice nursing within the professional and personal components of their lives. Sometimes, APRNs are in the position of guarding the boundary, such as when they are approached to undertake a task that is not within their scope of practice. Productivity requirements mean that APRNs must be clear about the numbers and types of patients that they can care for on a given day. Often, managing boundaries means extending them—building a bridge that enables the APRN to partner with other groups or expanding a boundary as other patient or health care needs are identified. For example, although CRNAs may not need prescriptive authority in a given state, they assist other APRN colleagues in their quest for state prescriptive authority. Extending a boundary may also mean expanding one's scope of practice at an agency level so that patient needs can be better met. Boundaries in practice tend to be fluid and often situation dependent. For example, in some practices, family NPs treat patients in the emergency department of the hospital, whereas in others only ACNPs treat patients there. Pushing boundaries in practice is usually based on education and experience in a particular area. That may mean that the APRN will have to acquire new training or credentialing in an area or technique and then be supervised in performing this new skill before expanding the boundary in autonomous practice. As boundary managers, APRNs recognize communications and behaviors that breach or enhance interpersonal relationships. APRN leaders also teach others how to collaborate with colleagues in other disciplines, build coalitions, and set limits while maintaining their own boundaries—a fine distinction, but strategically important. For example, a CNM may negotiate the boundaries or responsibilities among the neonatologist, obstetrician, and nurse-midwifery staff. Clinical leadership and professional leadership require the negotiation of boundaries, regardless of whether the borders are drawn around professional roles, patient populations, or organizations. Important to this discussion is the issue that APRNs are people with lives outside their work. They are often spouses, parents, grandparents, members of their religious communities, and members of their broader community. Each of these components of their lives will carry boundary requirements in addition to their professional boundaries. There are no easy answers as to how to manage boundary issues that arise between personal and professional demands. APRN leaders will find an almost constant interplay between personal and professional boundaries. Grant (2013) pointed out that asking for help results in a cascade of important assistance from family and colleagues. The successful APRN leader is quick to ask for help and use that help to achieve goals. Self-Management/Emotional Intelligence Most people know when they have overextended themselves; their bodies give clues such as fatigue, stress signals, feelings of frustration, and even physical illness. One of the challenging aspects of being a good leader is the provocative realization that one is being asked to play many important cutting edge roles at the same time. These invitations are exciting and seductive because they open new opportunities and speak to the high regard that others have for the leader. For these reasons, it is easy for good leaders to overextend their activities well beyond manageable, realistic boundaries. The skills of being able to delegate tasks; say no and mentor others to take on some of the load; and enlarge the circle of leaders, strategists, and followers are integral to effective leadership. Unfortunately, the inability to set realistic personal boundaries can lead to stress, frustration, and burnout. Being a leader and competent APRN provider at the same time is not easy, but it can be done. This skill requires APRNs to decline a request when competing responsibilities make it not possible to accept the request. Skillful practice with saying “no” uses the sandwich technique. It begins with saying the larger “yes”—what the APRN is currently reaching for in the practice or trying to accomplish—followed by a firm “no,” and ends with a hopeful statement such as “Perhaps I can help you find somebody else” or “Maybe I can help in the future.” The goal is to leave the requester with a sense of respect and a better understanding of the APRN. The following is an example: “I am really trying to build the prenatal care outreach service to underserved women. So, I cannot serve on the hospital CEO search committee. Perhaps I can help you find another qualified CNM to serve.” The process of self-reflection is useful for APRNs to determine which personal and work characteristics seem to set off imbalances. Three strategies are useful and simple in concept but can be complicated in execution. First, expecting perfection is often a setup for imbalance. Keeping in mind the axiom, “Perfect is the enemy of good,” may help APRNs establish realistic expectations. Reframing the notion to “good enough for now” allows the leader to move along. Another strategy is for APRNs to examine what makes them say “yes” or “no.” It is easy to think, “If I just do this one more thing, everything will be fine.” One APRN kept a note on her phone reminding her either to decline something that would tip the scales to overcommitment or to buy time by asking, “Can I think about it and call you tomorrow?” One colleague avoids commitments that are large but far into the future; these are invitations for activities months or even years in the future. Such activities may not appear to threaten one's usual commitments and deadlines but, as the time to fulfill the commitment approaches, these commitments can become very threatening. The challenge for the APRN is to ensure that adequate time to plan for, develop, and organize the work is budgeted well in advance of the due date. The third strategy is to make appointments with oneself for important personal and professional activities. By putting these appointments into a calendar, APRNs can lessen the risk of giving away time that they need to maintain balance. Using “the three things rule” may be helpful; identify the three most important things that must be done before any new commitments are made or started. Respect for Cultural and Gender Diversity Successful APRN leaders strive for cultural competence and value diversity in their work. These attributes require awareness of one's own biases, attitudes, and behaviors that surface at all levels of interaction and in all settings. An APRN leader needs to serve as a role model by demonstrating respect for the cultural differences of individuals and constituencies in any given situation. When a systems framework is used for understanding a complex concept such as culturally competent leadership, four levels can be identified— societal, professional, organizational, and individual. For the APRN, the responsibility for culturally competent care includes all four of these levels. A useful aid for developing a sound respect for cultural diversity can be found in the Interprofessional Education Collaborative competencies developed in 2011 (see Chapter 12, Box 12.1, for this resource). Culturally competent care is delivered with knowledge, sensitivity, and respect for the patient's and family's cultural background and practices. Cultural competence is an ongoing process that involves accepting and respecting differences (Giger et al., 2007). This definition is built on the assumption that care providers are aware of and sensitized to their own cultural backgrounds and that they are able to integrate this sensitivity into their delivery of care. The interactive nature of caregiving requires the authentic engagement of the provider with the patient to appreciate and respond to differences that may affect giving or receiving care. A good example of the challenge that culturally competent care presents has been provided by Wheatley (2005). In this example, a group practice offered free car seats and training in their use to a group of parents, but no one took advantage of the gift. On debriefing, the providers learned that for this group of parents, using a car seat was an invitation to God to cause a car accident. Differences are issues for every person, and they become even more important when one becomes a leader and role model. Working with colleagues who are different provides APRNs with opportunities for soliciting information about others' experiences. Box 11.6 presents strategies for enhancing cultural awareness. Box 11.6 Strategies to Achieve Cultural Competence • Explore and learn about your own racial and ethnic culture and background. • Explore and learn about the different racial and ethnic cultures most frequently encountered in your practice. • Read ethnic newspapers, magazines, and books. • Listen to the music from a different culture. • Learn the language of a different culture. Become bilingual with the verbal and nonverbal behavior of the culture. • Take advantage of training opportunities to increase your cultural awareness and sensitivity. • Be able to identify personal biases and develop strategies to manage, eliminate, or sublimate those potentially damaging attitudes and behaviors. • When faced with a patient difficulties, consider whether unconscious biases may be operating for you or your colleagues. Adapted from Hanson, C. M., & Malone, B. (2000). Leadership: Empowerment, change agency, and activism. In A. B. Hamric, J. A. Spross, & C. M. Hanson (Eds.), Advanced nursing practice: An integrative approach (2nd ed., pp. 279–313). Philadelphia: Saunders. Gender can play an important component in leadership. Gender stereotypes can exert a strong influence similar to cultural stereotypes and affect the way a leader is viewed and how the leader actually performs (Burgess, Joseph, van Ryn, & Carnes, 2012). As with culture, successful leaders understand their own biases about gender, the role gender may play in the provision of care, and gender issues in team functioning. Global Awareness The world is highly interconnected and interdependent; this affects APRN leaders because issues such as access to care, patient safety, and quality care are global issues that are not confined to any particular geographic region. There are workforce challenges throughout the world, natural and human catastrophes occur with regularity, and there are fewer barriers to interactions among countries (Abbott & Coenen, 2008; Carter, Owen-Williams, & Della, 2015). APRN leaders interface with a multicultural workforce in their immediate setting or through professional organizations, and they are asked to lead multicultural teams (Nichols, Shaffer, & Porter, 2011). APRNs may look to other countries for problem-solving ideas or may be asked for consultation in person or via technology from health care providers across the globe. The sharing of new techniques, therapies, and knowledge resources is important as we work together to address global issues such as the global chronic illness epidemic, infectious diseases, and common health crises (Abbott & Coenen, 2008; World Health Organization, 2008). Nichols et al. (2011) have identified global competencies for nurse leaders as outlined in Box 11.7. In addition, they have outlined areas for nurse leaders to consider in development of a worldview that includes sense of self and space, cultural dress, family relationships and decision making, values and beliefs, nutrition habits, and religious preferences (Nichols et al., 2011). Friedman (2006) has termed this view global citizenship and suggested that individuals and groups in leadership positions have a responsibility to think and act as global citizens. There are several organizations that have a global perspective of their mission, which can be accessed for resources: Box 11.7 Global Competencies for Nurse Leaders Develop global mind-set and worldview: • Global environmental awareness • Cultural adaptation • Awareness of social, political, and economic trends Understand needs of technology: • Enhanced ability of communication and technology • Create global networks • Individuals can now drive change just as businesses used to drive change Respect diversity and cultivate cross-cultural competencies: • Institutional mergers and growth • Multicultural work force • Multicultural patient populations Adapted from Nichols, B., Shaffer, F., & Porter, C. (2011). Global nursing leadership: A practical guide. Nursing Administration Quarterly, 35, 354–359. • International Council of Nurses • World Health Organization • Sigma Theta Tau International • Pan American Health Organization Developing Skills as APRN Leaders There are formal and informal strategies that are useful when considering a leadership development plan. Students will need to have experiences in their educational program to help them develop leadership skills. These can occur in the classroom, clinical practice, and student leadership and health-related service projects. In general, lessons learned in one domain will apply to leadership situations in other domains. Health policy leadership is discussed separately because it has specific features that are somewhat different from the APRN's everyday leadership activities. Factors Influencing Leadership Development There may be a misconception that leadership is a trait that one is born with rather than a skill that can be learned. There are a number of resources that new APRNs can access to help them learn to be leaders. These resources include many of the attributes described in this chapter, such as education, experience, expert communication, networking, assertiveness, and collaboration. Zaccaro (2007) has argued that with increases in conceptual and methodologic resources, learned attributes are more likely to predict leadership than once was believed. Leadership represents complex patterns of behavior explained in part by multiple leader attributes (Zaccaro, 2007). In this section, we explore leadership traits and attributes of leadershipcompetent APRNs. Personal Characteristics and Experiences Allen (1998) explored the primary factors and individual characteristics that influenced leadership development in nurse leaders. Self-confidence, traced to childhood and subsequent risktaking behaviors, was reported as a critical factor. Feedback from significant others led to enhanced self-confidence over time. The nurse leaders also spoke about having innate qualities and tendencies of leaders, such as being extroverted or bossy and wanting to take charge, and about having roles as team captains and officers in organizations. They saw themselves as people who rise to the occasion. A third important factor was a progression of experiences and successes that were pivotal in moving them forward. Being at the right place at the right time and taking advantage of opportunities presented in those situations allowed them to grow as leaders. Closely aligned with this factor was the influence of people important to them, such as mentors, role models, faculty, and parents, who had the ability to encourage and provide opportunities for advancement. Personal life factors, such as time, family, health, and work schedules, influenced leadership development. For example, supportive spouses and relatives who assisted with family and home responsibilities and employers who were flexible were important to the leadership development process. Upon close examination, one can see that the leadership abilities grew out of a combination of education and learning opportunities and depended on the support of others. These same characteristics can be used by aspiring APRN leaders. Zaccaro, Kemp, and Bader (2004) have developed a model that describes distal attributes, including personality, cognitive abilities, motives, and values, along with proximal attributes, including social appraisal skills, problem-solving skills, expertise, and tacit knowledge. In this model, the leader's operating environment influences the trajectory toward success, which supports the importance of organizational culture described by Watkins (2013) (see “Mentoring” section earlier). Carroll (2005) identified six factors that were present in women leaders and nurse executives: personal integrity; strategic vision and action orientation; team-building and communication skills; management and technical competencies; people skills (collaboration, empowering others, valuing diversity); and personal survival skills. These factors share similarity with the attributes in Box 11.5. Strategies for Acquiring Competency as a Leader Formal educational opportunities in leadership are an expected part of APRN education. Opportunities to work with faculty and other mentors help students acquire leadership skills and further reinforce self-confidence as a leader. Running for office while a student or for local leadership positions in professional organizations and serving on local and national coalitions are other good strategies for developing this competency (Sandrick, 2006). Also, leadership conferences that foster effective communication and interaction are beneficial. Exemplar 11.2 shows how students can practice their leadership development while in school. Exemplar 11.2 Mentoring an Advanced Practice Nurse Student in Community Leadership John was required to complete a course in the family nurse practitioner program focused on health care leadership. John was not too sure just why this was required since his primary goal was to graduate and open a practice in northeast Alaska, where he would be providing care to Alaska Native people in a small village. This had been a long-term dream, and he had selected a very strong clinical program and an experienced Alaskan Native preceptor so he would be ready to begin providing care upon graduation. He was unclear about what leadership activities would be expected of him as a primary care provider. One of the assignments he had in the leadership course was to complete a community assessment of his future site of practice to determine areas in which he could lead change. John learned many things about his future practice site during this assignment. The community where he would be in practice did not have a potable water supply. Untreated water was taken from a nearby stream during the summer months, but the stream was frozen during the long and very harsh winter. Ice could be melted for water but there was no assurance that the water would be clean enough for drinking. John also learned that the sewage system was a “honey bucket” self-haul system that is nearly impossible for the elderly to use and exposed children to raw sewage. Working under the mentorship of his preceptor, who lived in the village, John began to grasp the scope of the problem and quickly learned that substantial leadership would be required to bring an acceptable and affordable solution to the problems of potable water and sewage management. Solutions suitable for other climates just would not work in this community. Previous plans had failed because they did not fit the culture of the community, could not survive the harsh winter climate or spring floods from ice dams on the river, and were far too expensive for the small community to afford. John also learned that what he thought was a simple issue was a very large problem and would likely take many years to remedy. He was able to engage community elders to begin the process of finding long-term solutions. He had skills in grant writing that were very useful in securing funds to help with the planning. Most of his success was a result of the excellent mentorship he received from both his faculty member and his Alaskan Native preceptor. They gently guided him through the many complex areas related to this problem. Following graduation and after beginning practice in the village, John has continued his leadership. A new drinking/washing water system is in place but work continues on the community sewage system. His project in his leadership class has led to a longer-term role in leading his village to build other needed infrastructure. Leadership skills are developed and enhanced over time and in many ways. Communication is one of the strengths often attributed to nurses; it is a skill that can be strengthened through practice. Staying connected is important for busy APRNs and can be achieved in a variety of ways, from social media and shared projects to attending conferences that allow for time to interact and problem-solve with colleagues about similar professional issues. A community of APRN leaders is important for faculty and students involved with raising the visibility of advanced practice nursing roles in their institutions and communities. Developing Leadership in the Health Policy Arena Health policy issues affecting APRNs and their patients, including strategies for political advocacy, are explored in Chapter 19. The following section describes how APRNs can develop skills to influence health policy through creative leadership and political advocacy, whether by means of local grassroots endeavors or directly through top government involvement. The term advocacy can be defined as the act of pleading another person's cause and is multifaceted with diverse activities (Halpern, 2002; Kendig, 2006): “the endpoint of advocacy is the health and welfare of the public” (Leavitt, Chaffee, & Vance, 2007, p. 37). APRNs are being called on, both collectively and individually, to make their voices heard as governments struggle with budget constraints and difficult decisions about health policies, organization, and the funding of health care programs. In the political arena, developing power and influence uses a number of leadership skills. Leadership strategies used by APRNs in the political arena include developing influence with policymakers, motivating colleagues to stay informed of current issues, and providing bridges to other leaders who have access to important resources. The policy arena is made of a variety of rules, regulations, laws, court opinions, funding strategies, and other interrelated areas. There is often no one simple approach to this area. Mentoring APRNs to understand their power and influence in the health policy arena is a key role for the APRN leader. The developmental process for becoming a political activist begins early in life with an understanding of how government and the political systems work. Focused understanding often begins when health policy is introduced in the nursing curriculum (see Exemplar 11.2). These students are usually coached to understand the power inherent in policymaking, the power of politics to influence practice, and the ways that they can influence the system, individually and collectively, to better their own practice and be high-level patient advocates. Faculty members keep students informed about key legislative issues and introduce them, through role modeling, to the role of political advocacy. Inviting APRN students to accompany faculty who are giving testimony at a legislative hearing is one way to model the advocacy role. Faculty may also be members of committees or boards that focus on policy issues, and students can accompany the faculty member in this work. Many professional organizations also offer tools about how to engage in the political process, such as the NACNS (2011) and the American Association of Nurse Anesthetists (2016; Zenti, 1998). There is no question that influencing policy takes substantial commitment, time, and energy. Timing is an important consideration. APRNs ask themselves several personal and professional questions to determine the degree of involvement and level of sophistication at which advocacy is to be undertaken, including the following: • What are my personal responsibilities related to wage earning, small children, dependent parents, single parenthood, health issues, school, and gaining initial competence as an APRN? • How can I best serve the APRN community at this time? • What data sources can I access that keep me informed and up-to-date? • What learning opportunities will help me be an effective APRN advocate? • How can I develop short-term and long-term plans for becoming a more politically astute advocate for myself, my patients, and nursing? • What do I care deeply about? • What am I able to commit to, based on the responses to these questions? APRNs will need to find an appropriate mentor once they have made a decision about the depth of involvement to which they can commit. There are numerous effective nurse leaders and advocates who are willing and able to move new advocates into positions to make positive changes in health policy. Opportunities for input and influence exist at various levels of the legislative process (Larson, 2004; Park & Jex, 2011; Winterfeldt, 2001; see Chapter 22). Using Professional Organizations to the Best Advantage For APRNs, close contact with their professional organizations is an important link for staying current of national and state policy agendas, finding a support network of like-minded colleagues, and accessing information about changes in credentialing and practice issues. This means being an active member of more than one affiliate organization to stay on the cutting edge of pertinent issues. Most APRNs are aligned with at least one nursing organization; those who aspire to an active role in influencing policy will need to have memberships in several. As new graduates move into diverse practice settings, they must align with the advanced practice nursing organizations that best meet their needs and offer the strongest support, choosing to engage actively in some and remaining on the periphery in others. Choosing the “right” organizations to belong to is based on particular needs, comfort level, specialty, and experience. Internships and Fellowships One excellent way to develop enhanced skills as an advanced practice nursing policy advocate is to apply for a national or state policy internship or fellowship. These appointments, which last from several days to 1 or 2 years, offer a wide range of health policy and political experiences that are targeted to novice and expert APRNs. For example, the Nurse in Washington Internship (NIWI), sponsored by the Nursing Organizations Alliance, is a 4-day internship that introduces nurses to policymaking in Washington, DC. This internship serves as an excellent beginning step in learning the APRN policy role. Federal fellowships and internships that link nurses to legislators or to the various branches of federal and state government are invaluable in assisting APRNs to understand how leaders are developed and how the system for setting health policy operates. New Modes of Communication The ability to communicate with others accurately, efficiently, and in a timely manner is a driving force in making effective change. There is substantial opportunity to share information and to engage with others at a distance (Wakefield, 2003). Time and distance are no longer serious obstacles to communication. The multiple modes of Internet access make virtual communication a reality. Obstacles to Leadership Development and Effective Leadership There are a number of areas in which leaders encounter obstacles to developing effective leadership. Some of these have been touched on earlier but there are other areas in which obstacles can arise in unanticipated ways. Clinical Leadership Issues APRNs can find that exerting clinical leadership can be challenging at times. Some health systems have archaic rules and regulations that can infect professional staff privileges and the ability for APRNs to lead. For example, some health systems do not credential APRNs as independent practitioners but rather as dependent practitioners. This means that records must be signed by another professional; admissions, transitions of care, and discharges are a challenge; and procedures or scope of practice can be restricted. The world of health care is changing and the astute APRN will keep pushing the boundaries in this area. Sometimes these issues can be resolved by creativity. For example, in one state there was a statewide regulation governing all hospitals that there must be a physician appointed to be the chief of the medical staff. The particular hospital wanted to appoint a CNM to be in charge of all clinical services offered by the hospital. This was done by appointing the CNM to the title of Chief Clinical Officer and having the Chief of the Medical Staff report to this position. This approach allowed the hospital to achieve its goal and to conform to state regulations. Many rules and regulations that limit practice will fall away as new APRNs join the team and their unique expertise is valued. Some hospitals that claim that they do not credential APRNs do credential CRNAs to practice. They would have to close their surgical services if they did not do so. The day will come when the rest of the APRNs will be viewed as similarly valuable. Professional and System Obstacles There are several obstacles to achieving recognition as an APRN leader. Most of the obstacles result from conflict or competition among individuals, groups, or organizations. These obstacles can develop as the scopes of practice of various professionals overlap in clinical practice. A lack of legal empowerment to practice to the fullest extent of knowledge and skills has been a dominant barrier to the optimal practice of APRNs in recent years. CNMs and CRNAs have the longest track record in America of dealing with these issues and have earned many successes. Competition can be intraprofessional, as among APRN groups, and interprofessional, as among pharmacists, optometrists, physicians, and nurses. One approach to good leadership is to focus on bringing dignity to self and others rather than being liked; for most people, this is difficult because being accepted and liked by others is important. Trying to do it all rather than delegating to others is a common challenge for busy leaders. As noted, a good leader can encourage a shared workload that recognizes the talents and abilities of followers. Dysfunctional Leadership Styles Leadership can be a lonely place, and successful leadership requires careful nurturing. Although good leaders are sought after and desired, we have all experienced the other side of the coin—a dysfunctional leader. There are a multitude of traits and styles that can be attributed to a dysfunctional leader, such as micromanager, passive-aggressive, narcissistic personality, conflict avoidant, a quest for personal power, and a game player. The dictatorial leader or the leader who is most interested in empire building is easily recognized. Dysfunctional leaders often have poor self-control, have no time for others, or fail to accept responsibility for their own actions. At its worst, dysfunctional leadership moves into the realm of horizontal violence. Horizontal Violence Horizontal violence is described as an aggressive act carried out by one colleague toward another (Longo & Sherman, 2007). This type of behavior is often seen among oppressed groups as a way for individuals to achieve a sense of power. Some of these behaviors are being overly critical, intentionally undermining another's actions, fighting among colleagues, and wrongfully blaming others. These behaviors leave one feeling humiliated and overwhelmed and unsupported. Although there are many barriers to leading effectively and creating community, several constellations of behaviors that are particularly destructive have been identified. Nurses may be vulnerable to these destructive behaviors because of the profession's historical marginalization as being female and a relatively powerless group in health care. The culture of an organization as described earlier is also a factor in the development of these dysfunctional styles. These behaviors undermine successful APRN leadership. APRNs must avoid engaging in such behaviors and intervene assertively when they do occur. Four manifestations of horizontal violence in workplace culture limit the ability of APRNs to lead: the star complex, the queen bee syndrome, failure to mentor (“eating one's young”), and bullying. These behaviors are of particular concern because the profession needs to recruit and develop new nurses to help them have satisfying careers and pass on the legacy of a satisfying career to future generations of nurses. Faculty and preceptors need to be alert to the appearance of such toxic behaviors and assure that they are not tolerated. Readers are referred to the articles by Anderson (2011), Longo and Smith (2011), King (2002), Rider (2002), Longo and Sherman (2007), and Bally (2007) for specific suggestions on strategies for communicating with students and colleagues who demonstrate these negative interpersonal styles. Abandoning One's Nursing Identity: Star Complex Effective APRN leaders are proud of their identity as a nurse. Those with a star complex deny or minimizing their nursing identity when being identified as a nurse might diminish their influence. The star complex is a condition that is seen in some experienced APRNs or in APRNs who have not been well socialized into nursing as a profession. Individuals with a star complex are those whose sense of self and identity depend a great deal on the opinions of powerful others. Acknowledging or promoting their identity as nurses is seen to diminish their power or the opinions that powerful others hold about them. As an example, consider Janice, an expert APRN who provides superior patient-focused care. Physician colleagues consider her to be a partner in the delivery of care, but staff and other APRNs gave up consulting with her because her self-promotion often interfered with patient and colleague interactions. In a recent conversation, a wellrespected physician colleague told her how impressed he was with her practice. “In fact,” he stated, “you're really not a nurse. You're different from all the other nurses I know.” Janice graciously accepted this compliment, knowing that stardom, although overdue, had finally arrived. She had ascended to the heights of provider status and crashed through the nursing ceiling into a zone beyond nursing. Clearly, Janice's understanding of herself as an APRN was dormant. APRNs are particularly vulnerable to being seduced into believing that they are something other (more) than a nurse. Advanced practice nursing specialties that have expanded roles may seek the status of medicine. This vulnerability stems from the historical lack of recognition of nursing by physicians, other disciplines, and even other nurses; the need for approval; and a lack of personal mastery. A primary strategy for the management of this obstacle is effective mentoring by a powerful APRN with a strong nursing identity. An additional essential strategy is to use clear and concise communication skills to provide an appropriate response to a colleague who believes that it is a compliment to be identified as other than a nurse. An appropriate response for Janice to have made would have been, “Thank you, but I'm proud to be an APRN. It is good that we can work together to help our patients.” The existence of a star complex may represent a more fundamental problem for the APRN than good communication skills can address. The issue is whether the APRN truly desires to be identified as a nurse, performing at the boundaries of nursing practice and being accepted by other nurses as a valued member of the nursing profession. As APRNs are increasingly recognized as valued members of the health care team and as mentoring and empowerment become understood as core elements of leadership, star complex behavior will become less tolerated, unnecessary, and less frequent. Hoarding or Misusing Power: Queen Bee Syndrome An effective leader is generous, looking for opportunities to lift colleagues up by sharing opportunities, knowledge, and expertise and acknowledging the contributions of others. Queen bee syndrome refers to individuals who believe they have achieved a level of prominence by their own individual hard work, with little or no assistance from others, and that everyone else should do the same. These people hoard all the visible leadership tasks for themselves. Like those with a star complex, the effort to garner power is a theme. In this case, power derives not from powerful others but from the queen bee's own knowledge and expertise. Such APRNs are threatened by strong individuals and tend to denigrate them instead of sharing power. This type of leader prefers to be surrounded by servile individuals who will not challenge personal authority. For example, Rita, an experienced wound and ostomy APRN, makes sure that she sees every patient and that patients know she is the authority on wounds and ostomies. Staff nurses who are competent in these skills report that Rita undermines them with patients by saying that the care should have been done a certain way. Rita was not happy when the staff on a surgical unit, who had tried unsuccessfully to involve her in a unit project, conducted a quality improvement project during which both physicians and patients identified some service delivery issues relative to ostomy care. These staff members changed the way wound and ostomy services were managed. The antidote to a queen bee syndrome is to use knowledge and expertise to move away from hoarding power toward collaborative, empowered leadership. Queen bee behavior is the antithesis of good leadership. Queen bees will have more difficulty remaining as leaders and keeping positions of power as APRN become more confident in their leadership abilities and join the circle of leaders. All effective leaders empower others. Failure to Mentor A distressing form of horizontal violence is common. “Nurses eat their young” is an epithet that characterizes the experience of many novice nurses and APRNs, as well as of some older, more experienced nurses (Baltimore, 2006). Nurses who advance in their profession may forget their roots and leave novice nurses behind or, worse, actively undermine their advancement. For example, nurses are often criticized by other nurses for continuing their education and moving into APRN roles. This denigration of important values and goals by colleagues is dispiriting and discouraging; it can hamper nurses from moving forward in their careers. In another example, the orientation process for a new position may become a survival test to see whether the new APRN can survive without mentoring or a supportive network. Because perceived powerlessness is at the root of this behavior, an important antidote is empowerment. The common practice of mentoring, taking an active interest in another's career, apprenticing, and “giving a leg up” to the least experienced is not as common in nursing as it is in many other professions. Box 11.8 lists the behaviors that provide evidence that there has been a failure in mentorship (Baltimore, 2006; Longo & Sherman, 2007; Longo & Smith, 2011). Box 11.8 Failure in Mentorship Behaviors • Gossiping or bad-mouthing • Criticizing • Failure to give assistance when needed • Setting up roadblocks by withholding information • Bullying • Scapegoating • Undermining performance Bullying Bullying is a severe form of horizontal violence attributed to oppressed group behavior. Plonien (2016) and the American Nurses Association (2015) have suggested that horizontal violence is a more complex phenomenon and includes those external to nursing who make up the organization's culture and add to stress in the work setting. Curran (2006) reported that there will be more career nurses vying for leadership positions and that forms of horizontal violence such as bullying will worsen. Bullying is not a one-time event but instead is a subtle, deliberate, and ongoing behavior that accumulates over time and leaves the victim feeling hurt, vulnerable, and powerless (Anderson, 2011; Hutchinson, Vickers, Jackson, & Wilkes, 2005; Longo & Sherman, 2007). Strategies to Overcome Horizontal Violence Personal and organizational symptoms of horizontal violence are job dissatisfaction, increased stress levels, and physical and psychological illness. If the broader cause is a negative organizational culture, then the most effective leadership strategy to prevent its occurrence is to adopt a zero tolerance policy and a shared set of values with the staff (Longo & Sherman, 2007; Longo & Smith, 2011) that support positive behaviors. For example, fostering mentoring opportunities and enhancing the transition of colleagues into new positions of leadership can create a positive culture that does not tolerate horizontal violence. Box 11.9 presents suggested leadership strategies to eliminate horizontal violence. Box 11.9 Leadership Strategies to Stop Horizontal Violence • Examine the organizational culture for symptoms of horizontal violence. • Name the problem as horizontal violence when you see it. • Educate staff to break the silence. • Allow victims of horizontal violence to tell their stories. • Enact a process for dealing with issues that occur. • Provide training for conflict and anger management skills. • Empower victims to defend themselves. • Engage in self-reflection to ensure that your leadership style does not support horizontal violence. • Encourage a culture of zero tolerance for horizontal violence. Adapted from Longo, J., & Sherman, R. O. (2007). Leveling horizontal violence. Nursing Management, 38, 34–37, 50–51. Negative behaviors that are expressed as failure to mentor, bullying, and disenfranchising others may continue to be present in an increasingly stressful health care environment (McAvoy & Murtagh, 2003; Thomas, 2003). It is not an overstatement to claim that the future health of the profession depends on overcoming this barrier and relegating it to history. APRN leaders as role models create a more empowering and humane work environment for their colleagues and those who follow them. Strategies for Implementing the Leadership Competency Developing a Leadership Portfolio Throughout this chapter, definitions, attributes, and components of leadership and key strategies for developing competency in APRN leadership have been presented. These approaches will help new APRNs acquire leadership skills and can assist faculty in teaching these skills. Developing a leadership component as part of a professional portfolio is helpful to novice APRNs who desire to individualize continuing development of the leadership competency consistent with their personal vision, goals, timeline, and APRN role in the practice setting. An Australian study reported increased knowledge, skill sets, and outcomes in clinicians and leaders who used portfolios to enhance their effectiveness (Dadich, 2010). Falter (2003) has suggested the use of a strategy map that includes vision, goals, and objectives that outline steps to achieve a particular strategy. Portfolios are designed to meet the needs of individual APRNs and should be consistent with clinical and personal interests and professional goals and provide a timeline that allows for personal and professional balance and boundary setting. Chapter 20 provides the elements of a marketing portfolio. Promoting Collaboration Among APRN Groups At different times, each subgroup of APRNs in America has emerged as a leader for the nursing profession. Psychiatric CNSs were early APRNs to enter private practice, despite the litigious climate in which they could be threatened with lawsuits for “practicing medicine.” CNMs and CRNAs have led the way in using data effectively to justify their practice and attain appropriate scopes of practice. Early in their history, both groups began to record the results of their practices, showing the quality and suitability of their care (see Chapter 1). In the 1990s, NPs, with their flexible, community-based primary care practices, stood at the forefront of the changing health care delivery system. Although these subgroups of APRNs have made impressive strides, an obstacle to effective leadership is the tendency for APRN specialty groups to separate and establish rigid boundaries that distinguish them from one another, thereby fragmenting APRN groups and blocking opportunities for the increased power that unity would bring. The tension and fragmentation created by rigid boundaries require leaders who can transcend APRN roles and specialties. Consensus groups have developed at the national level to discuss policy issues in which the power of the collective numbers of all APRN groups speaking with one voice cannot be overemphasized (see Chapters 2, 12, and 22). An excellent example of professional collaboration among nurse leaders is the Consensus Model work (Chapter 22). APRN organizations have joined to speak out collaboratively about state regulations regarding reimbursement, prescriptive authority, and managed care empanelment. Each APRN, regardless of specialty, has the responsibility of moving toward an integrative and unified understanding of advanced practice nursing. Creating community in the current health care environment is particularly challenging because of the realignment of clinical decision making, changing scopes of practice for APRNs, and new roles that blur boundaries between and among providers. An understanding of change, effective communication, coalition building, shared vision, and collaborative practice leads to the development of structures on which unity is built. These five building blocks form the foundation of interprofessional leadership and practice. Networking Networking is a valuable technique used by leaders to stay informed and connected regarding APRN issues. Networking is not a new strategy for APRN leaders. Formal networks take the form of committees, coalitions, and consortia of people who come together to share information, collaborate, and plan strategy regarding mutual issues. Formal networks open doors to new opportunities and provide shared resources that ensure a competitive edge in the organization (Carroll, 2005). Informal networking is a strategy that takes place behind the scenes and allows for contact with APRNs and others who speak similar language, share viewpoints, and offer support and feedback at critical times. The ability of APRNs to stay connected to important practice and education issues through networking is key to leadership competency. The most effective strategy for becoming an insider is networking with colleagues within the circle of APRN peers and with other health care providers who have a stake in the outcomes of a particular issue. Effectively Working With Other Leaders to Advance Health Care Other strategies also assist in the process of planning and implementing change. It is important to analyze the situation and explore the need for change. If change is warranted, one must craft an implementation plan that involves the key players. Box 11.3 lists leadership strategies that are useful for moving through these transitions. Bonalumi and Fisher (1999) have suggested that an important component of leadership during times of change is the ability to foster and encourage resilience in change recipients. O'Connell (1999) and Grafton, Gillespie, and Henderson (2010) have defined resilient people as being positive and self-assured in the face of life's complexities; having a focused, clear vision of what they want to achieve; and having the ability to be organized but flexible and proactive rather than reactive. Helping colleagues and followers develop resilience should be a major focus for APRN leaders who seek to facilitate the growth of their followers. Institutional Assessment Regarding Readiness for Change With the emphasis on evidence-based practice and the knowledge that evidence-based guidelines and therapies are underused (IOM, 2001; McGlynn et al., 2003), overused, or misused (IOM, 2001), APRNs have an important systems leadership role in improving care. This can be accomplished by leading and collaborating with nurses and interprofessional colleagues to ensure the adoption of best practices (Duffy, 2002; Spencer & Jordan, 2001; Spross & Heaney, 2000; Weaver, Salas, & King, 2011). An institutional assessment of specific factors will help the APRN identify facilitators of and barriers to change. These data can then be used to design a plan for change in collaboration with others. Box 11.10 lists key assessment questions to consider. Box 11.10 Assessment Questions to Evaluate Readiness for Change • What is the nature of the change (e.g., policy, procedure, new skill, behavior)? • Is the issue significant? For all stakeholders or just one group? • Is a national policy, guideline, or standard the focus of the change? Is it a mandate with which the agency must be in compliance? • Is the change simple or complex? Will different stakeholders perceive its simplicity or complexity differently? • Do you foresee major problems associated with change, such as an increase in errors or resistance on the part of a group? • Will it be possible to address these major problems? • Are there vested interests—who is likely to gain from the change, who will view the change as a loss (e.g., of power)? • Are there opinion leaders who will promote the change? Do you anticipate strong opposition? • Have you observed a gap between public statements and private actions (e.g., a colleague agrees to serve on a committee but never shows up or participates in the committee's work)? • Are there resource implications? What are the costs (e.g., staffing, materials, lost revenue)? Adapted from the University of York National Health Centre for Reviews and Dissemination. (1999). Getting evidence into practice. Effective Health Care Bulletin, 5, 1–16. Followship As APRNs focus on developing their leadership skills, they discover the importance of being a good follower. Skill is necessary to recognize when one should be a follower rather than a leader—when another is more skilled or more appropriate to lead a particular situation, or when it is appropriate to let others who are developing leadership skills take the lead on a project. Successful collaboration and teamwork require not just leadership but skilled followers as well. Expert followers know how to accept direction, be forthcoming with pertinent information that is valuable to the team, seek clarification, and provide appropriate constructive feedback. Conclusion The health care system is constantly evolving and while this evolution can appear rather chaotic at times, most of the changes seen are the results of leadership. This means that the future is bright for APRNs as clinical, professional, health policy, and systems leaders. APRNs can exert their leadership influence in far-reaching ways, from the bedside and clinic to the highest political office. APRNs are also constantly evolving in all the various roles, and these changes have had substantial influence on the health care system, as well as on the nursing profession itself. APRNs exercise leadership when they present ideas or dilemmas and offer solutions to colleagues or communities, whether through social media or at a national meeting. Small changes often lead to much larger changes, so APRNs should not underestimate the impact of leadership exercised with patients, colleagues, and administrators. APRNs can consider how they can lead, make a difference, and commit to doing so, knowing that they can redefine the scope of their leadership influence in response to opportunities or changing life circumstances. The dynamic, everchanging environment of health care sets the stage for ceaseless opportunities for APRNs to innovate and lead. Nursing practice is based on an interactive style that empowers patients and colleagues. This foundation holds APRN leaders in good stead as they move into the emerging interprofessional practices that are developing. APRNs can work toward identifying, clarifying, and demystifying the health care system of today, for within today's reality lies the basis of tomorrow's change. APRNs are poised to lead change as they operate at the boundary between today's health care system and that of tomorrow. The attributes, goals, and vision of APRN leaders put them at the forefront of the health care frontier. 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Journal of the American Association of Nurse Anesthetists. 1998;66:19–22 [Retrieved from] www.aana.com/newsandjournal/Documents/washington_scene_0298_p0 CHAPTER 12 Collaboration Michael Carter, Cindi Dabney, Charlene M. Hanson “For the strength of the pack is the Wolf, and the strength of the Wolf is the pack.” —Rudyard Kipling CHAPTER CONTENTS Definition of Collaboration, 286 Collaboration: What It Is, 286 Collaboration: What It Is Not, 287 Domains of Collaboration in Advanced Practice Nursing, 289 Collaboration With Individuals, 289 Collaboration With Teams and Groups, 289 Collaboration in the Organizational and Policy Arenas, 289 Collaboration in Global Arenas, 289 Terms of Collaboration, 289 Interprofessional Collaboration, 290 Characteristics of Effective Collaboration, 290 Clinical Competence and Accountability, 293 Common Purpose, 293 Interpersonal Competence and Effective Communication, 294 Recognizing and Valuing Diverse, Complementary Culture, Knowledge, and Skills, 294 Humor, 294 Impact of Collaboration on Patients and Clinicians, 295 Evidence That Collaboration Works, 296 Research Supporting Interprofessional Collaboration, 296 Effects of Failure to Collaborate, 298 Imperatives for Collaboration, 298 Ethical Imperative to Collaborate, 299 Institutional Imperative to Collaborate, 299 Research Imperative to Study Collaboration, 300 Context of Collaboration in Contemporary Health Care, 300 Incentives and Opportunities for Collaboration, 300 Barriers to Collaboration, 301 Processes Associated with Effective Collaboration, 304 Recurring Interactions, 304 Effective Conflict Negotiation and Resolution Skills, 304 Partnering and Team Building, 304 Implementing Collaboration, 304 Assessment of Personal and Environmental Factors, 305 Strategies for Successful Collaboration, 305 Individual Strategies, 305 Team Strategies, 306 Organizational Strategies, 307 Conclusion, 307 Key Summary Points, 309 Advanced practice nursing is highly complex and requires that the advanced practice registered nurse (APRN) be competent in collaboration. Collaboration takes place in a number of reciprocal relationships and includes the APRN, the patient, families, other health care providers, and a number of others who are a part of the treatment experience. Patients assume that their health care providers communicate and collaborate effectively and become concerned when this does not occur. Patient dissatisfaction with care, unsatisfactory clinical outcomes, and clinician frustration can often be traced to a failure to collaborate among those caring for the patient. Collaboration depends on clinical and interpersonal expertise and is built on strong collegial relationships. The primary focus of this chapter is on collaboration among individuals and work groups. The goal is to make explicit the values, behaviors, and processes that facilitate collaboration and thus improve patient care. Definition of Collaboration Collaboration: What It Is The term collaboration is often used in health care and is associated with teamwork and partnership. These are necessary components of collaboration but are not sufficient. The American Nurses Association's (ANA's) Nursing's Social Policy Statement (ANA, 2010) clarifies that collaboration for nurses, including APRNs, means a true partnership in which there is a valuing of expertise, power, and respect for all members. Collaboration also means recognizing and accepting each participant's sphere of activity and responsibility. The Essentials of Doctoral Education for Advanced Nursing Practice, released by the American Association of Colleges of Nursing (AACN) in 2006, specifies that APRNs are expected to provide interprofessional collaboration for improving patient and population health outcomes. APRNs are expected to establish, participate, and lead collaborative teams when appropriate. Hanson and Spross' (1996) earlier definition of collaboration is still appropriate today: Collaboration is a dynamic, interpersonal process in which two or more individuals make a commitment to each other to interact authentically and constructively to solve problems and to learn from each other to accomplish identified goals, purposes, or outcomes. The individuals recognize and articulate the shared values that make this commitment possible. (p. 232) Characterizing collaboration as an interaction conveys the communicative and behavioral aspects of this competency. This definition implies partnership, shared values, commitment, and goals yet allows for differences in opinions and approaches. Including the notions of shared values and commitment makes it clear that collaboration is a process that evolves over time. The Interprofessional Education Collaborative (IPEC) (2011) has developed four core competencies of collaborative practice for health professionals. These focus on values and ethics, roles and responsibilities, communication, and teamwork across the full spectrum of care. Additionally, the Institute of Healthcare Improvement (2017a) has developed a Triple Aim framework dealing with improving the patient experience of care, including quality and satisfaction with care; improving the health of populations; and reducing the per capita cost of health care. These aims can only be achieved through collaborative practice for health professionals. The ability to commit to interprofessional interaction over time requires that participants bring a set of characteristics and qualities to the encounter. To interact authentically means partners share the emotional satisfactions and frustrations of clinical work and develop ways of supporting each other. Successful collaboration can lead to an intimacy that arises from working closely together over time. A collaborative practice may include the challenge of dealing with the same person(s) daily over clinically important matters that are large or small. Managing conflict and engaging in crucial conversations are key to success and require the skills found in the definition of collaboration. Collaboration requires relationships that are productive for professionals, patients, and communities. There is room for disagreement in collaborative relationships; partners and teams develop strategies for dealing with disagreements that are mutually satisfactory and enhance the process. Collaboration demands a sophisticated level of communication; collaboration cannot be mandated, legislated, or regulated. Collaboration: What It Is Not Several forms of interaction occur among clinicians, patients, families, and administrators in the complex processes that occur in care delivery. Collaboration is likely the most sophisticated and complicated among these forms. At times there can be confusion as to what collaboration is and what other forms of communication exist. These other forms listed below do not meet the definition of collaboration used by the nursing profession. With the exceptions of parallel communication, the processes described here require some level of interaction among providers but may not involve collaboration. Information exchange, coordination, consultation, co-management, and referral may be sufficient to achieve clinical goals in particular situations. Effective and timely communication is required among clinicians for these processes to work to benefit patients, minimize errors, and enhance quality. Parallel Communication. Parallel communication occurs when clinicians interact with a patient separately. They do not talk together before seeing a patient nor do they see the patient together; there is no expectation of joint interactions. For example, the staff registered nurse, medical student, attending physician, acute care nurse practitioner (NP) and the certified registered nurse anesthetist (CRNA) all ask the patient the same questions about medications. In this example, multiple interactions are burdensome and frustrating for the patient. The patient is inconvenienced, and fragmented information has been gathered from multiple sources that may lead to errors in clinical decision making. This practice of asking the same question is often perceived as a safety issue, requiring different providers to ask the same questions, especially regarding medication review and reconciliation. The patient expects that, at the minimum, the information is captured in the medical record and all those involved with care will read and understand this information. Repeated questioning over the same topic can be interpreted as either the information was not recorded or the clinician failed to read the record. One-Sided Compromise. Communication that demonstrates a one-sided compromise occurs when the APRN is overly agreeable, consistently yields to the other health care providers, and senses a personal lack of integrity in the care. This yielding results in compromised care and occurs when the APRN lacks the will or skill to engage in a collaborative negotiation. Faux Collaboration. Faux collaboration occurs when persons in a position of authority believe that they are being collaborative because those around them are agreeing with the authority figure but not engaging in meaningful dialogue. This form of communication can be rather subtle and difficult for others to understand. Parallel Functioning. Parallel functioning occurs when providers care for patients, addressing the same clinical problem, but do not engage in any joint or collaborative planning. For example, nurses, physical therapists, and physicians document their interventions for pain in separate parts of the patient record but do not communicate about the case. The effect of such interactions is the same as for parallel communication. Information Exchange. Informing may be one-sided or two-sided and may or may not require action or decision making. If action is needed, the decision is unilateral, not a result of joint planning. Information exchange may be sufficient and exert a neutral or beneficial effect on care processes and outcomes. There is a risk of a negative outcome if the situation actually requires joint planning and decision making. Coordination. This form of communication lends structure to the encounter and may include actions to minimize duplication of effort but not interaction. Calling the supplier to assure that the patient receives the durable medical equipment needed following an office visit is one way that the APRN may engage in coordination. This form of communication is usually one-sided and direct and may achieve the goal, but this is not collaboration. Consultation. The clinician who is caring for a patient seeks advice regarding a patient's concern but retains primary responsibility for care delivery (see Chapter 9). For example. the certified nurse-midwife (CNM) may believe that there is a need for an evaluation and recommendation for treatment of a mother who is experiencing symptoms of depression and asks for a consultation by the psychiatric/mental health nurse practitioner. The result is a recommendation to the CNM for treatment of the mother, but the CNM retains the responsibility of actually prescribing the intervention if the recommendation is determined to be appropriate. Co-Management. Two or more clinicians provide care and each professional retains accountability and responsibility for defined aspects of care. This process usually arises from consultation in which a problem requires management that is outside the scope of practice of the referring clinician and the treatment will be continuing (see Chapter 9). Providers must be explicit with each other about their responsibilities. Co-management may also be a process used by interprofessional teams, such as palliative care. There is the possibility that comanagement can become parallel functioning, and this should be avoided. Referral. A referral occurs when the APRN directs the patient to another clinician for the management of a particular problem or aspect of the patient's care when the problem is beyond the APRN's expertise (see Chapter 9). For example, the APRN may determine that a patient could benefit from a course of physical therapy and a referral is initiated, or the APRN decides that the patient has appendicitis and requires surgery, so a referral to a surgeon is initiated. Supervision. Some clinicians may confuse collaboration with supervision. Supervision occurs when one clinician delegates aspects of care to another clinician but retains full authority for the care. Authority and accountability for all aspects of the care are retained by the supervisor and billing for the care is done by the supervisor. All APRNs are autonomous practitioners and supervision of them by other disciplines is not appropriate. APRNs may supervise other nursing personnel for aspects of nursing care they provide but are not appropriate to supervise other disciplines. Domains of Collaboration in Advanced Practice Nursing APRNs execute the collaboration competency in several domains— among individuals, work groups, and organizations. Competency in collaboration is often executed at the same time as other competencies, and it is dynamic, shifting as the particulars of a situation change. Collaboration With Individuals Collaboration with patients, families, and colleagues in the delivery of direct care is the primary domain in which collaboration is practiced. For example, in forming partnerships with patients (see Chapter 8), APRNs aim to understand how the patient wants to interact, and in turn collaborate with patients and families when they mutually set and revise goals and determine barriers for outcomes; these activities are aimed at uncovering a common purpose, a hallmark of collaboration. APRNs also collaborate with individual clinicians. For example, the diabetes clinical nurse specialist (CNS) may collaborate with the cardiac CNS and a staff nurse to determine who will carry out which aspects of patient education for a patient. The collaborative process may include determining the order and timing of content to be taught. In this case, the APRN is also executing the direct care (interacting with the patient to assess learning needs) and guidance (guiding patients in lifestyle changes) competencies. Collaboration With Teams and Groups Another common domain in which APRNs implement collaboration is in their work with clinical teams and on departmental and institutional committees. These groups may be composed of individuals from multiple disciplines. A key function of the collaborative competency is the facilitation of teamwork to ensure the delivery of effective, safe, high-quality care leading to positive outcomes. APRNs play key roles in facilitating and leading interprofessional teams, which ultimately requires integrated collaboration of leadership competencies. As APRNs become more experienced, their skill in facilitating collaboration in groups grows. Collaboration in the Organizational and Policy Arenas In this domain, the focus of collaboration extends beyond the delivery of care to individuals and groups. The organizational and policy forces shaping advanced practice nursing and clinical care require that even novice APRNs cultivate collaboration. Initiatives aimed at clarifying credentialing requirements, making it easier to practice across state lines, and improving reimbursement for APRNs require them to use their status as clinicians, citizens, and members of professional organizations to collaborate with organizational leaders and policymakers. Collaboration in Global Arenas Global or international collaboration is becoming an essential domain for APRNs, as noted by the AACN (2006), the Institute of Medicine (IOM, 2011; IOM, Committee on Quality Health Care in America, 2001), and the National Organization of Nurse Practitioner Faculties (NONPF, 2012; see also Chapter 6). Friedman (2005) has argued that global communication and collaboration will be the keys to successful living, working, and economic success over the next century, and we believe that this is true for health care. There is evidence that globalization is already affecting practice; the APRN covering the emergency room at night may be communicating with a radiologist in Australia about a diagnostic image that was sent electronically to be interpreted in real time. In addition, APRNs' experiences with volunteerism in other countries (e.g., Doctors Without Borders, mission trips to Haiti and Africa) are shaping their goals and opportunities. Terms of Collaboration The terms multidisciplinary, interdisciplinary, transdisciplinary, and, most currently, interprofessional collaboration are often used interchangeably. There are differences among these terms; the prefix actually indicates the level and depth of interactions to which the term refers. Choi and Pak (2006) provided a review of the key differences among the terms. Multidisciplinary teams use the knowledge from different disciplines, but these teams stay within their own boundaries. Interdisciplinary teams blend the various disciplines into a single whole. Transdisciplinary teams integrate the sciences with the humanities and move beyond usual boundaries. This clearly defined idea of interprofessional collaboration moves beyond these traditional forms of teamwork and takes these types of collaboration a bit further in an attempt to eliminate traditionally prescribed boundaries through negotiation and interaction (Alberto & Herth, 2009; Bainbridge, Nasmith, Orchard, & Wood, 2010; IPEC, 2011). Interprofessional collaboration occurs when more than one professional works together to focus on a particular health problem or concern. Interprofessional collaboration requires that there be mutual respect and commitment for the sake of a response to a problem. Petri (2010) has suggested that it is an interpersonal process characterized by health care professionals with shared objectives, decision-making responsibility, and power working together to solve patient care problems. The Interprofessional Collaborative Initiative (IPEC, 2011; Schmitt, 2011) is a partnership made up of the AACN, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health. This group takes this definition further with their goal of preparing all health professions students to work together deliberatively to build a safer and better patient- and community-centered health care system in the United States. IPEC has developed a framework for interprofessional collaborative practice based on four domains, described in Box 12.1. Each IPEC domain has several behaviors that further define the competency (IPEC, 2011). Box 12.1 Interprofessional Collaborative Initiative Domains and Competencies Competency Domain 1: Values and Ethics for Interprofessional Collaboration • Place patients and populations at center of care. • Respect dignity and privacy of patients and confidentiality of team members. • Embrace cultural diversity. • Respect unique cultures, values, and roles. • Work in cooperation with patients and providers and those who support care. • Develop trusting relationships with patients, families, and team members. • Demonstrate ethical conduct and quality care as a member of the team. • Manage ethical dilemmas in interprofessional care situations. • Act with honesty and integrity. • Maintain personal and professional competence. Competency 2: Roles and Responsibilities for Collaboration • Communicate role and responsibilities clearly to patients and professionals. • Recognize skill, knowledge, and ability limitations. • Engage with professionals who complement one's practice. • Explain roles and responsibilities of other team members. • Use the full scope of the knowledge, skills, and abilities of all team members. • Communicate with the team to clarify roles and responsibilities. • Forge interdependent relationships. • Engage in continuous interprofessional development. • Use unique and complementary abilities of all members to optimize care. Competency 3: Interprofessional Communication • Choose effective communication tools to enhance team function. • Communicate information to patients and team members, avoiding discipline-specific terminology. • Express knowledge and opinions to team with confidence, respect, and clarity to ensure common understanding. • Listen actively and encourage ideas and opinions of other team members. • Give timely, sensitive, and instructive feedback to team members about their performance and respond respectively to feedback from others. • Use respectful language in difficult situations or interprofessional conflict. • Recognize one's own uniqueness and contributions to effective communication, conflict resolution, and positive working relationships. • Consistently communicate the importance of patient-centered care. Competency 4: Interprofessional Teamwork and TeamBased Care • Describe the process of team and role development and the role and practice of effective teams. • Develop consensus on ethical principles to guide all aspects of patient care and teamwork. • Engage other health professionals in shared, patient-centered problem solving. • Integrate knowledge and experience of other professionals to inform care decisions while respecting patient and community values and priorities. • Apply leadership practices that support collaborative practice. • Engage self and others to manage constructively any disagreements about values, roles, and goals of care. • Share accountability with other professionals, patients, and communities for relevant health care outcomes. • Reflect on individual and team performance to improve individual and team performance. • Use process improvement strategies to improve the effectiveness of interprofessional teamwork and practice. • Use available evidence to inform effective teamwork and teambased practice. • Perform effectively on teams and in different team roles in a variety of settings. Adapted from Interprofessional Education Collaborative. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Retrieved from http://www.aacn.nche.edu/education/pdf/IPECreport.pdf. The move to reintroduce team approaches to care is evident across the spectrum of health care today (Clausen et al., 2012; IOM, 2011; Patient Protection and Affordable Care Act [ACA], 2010; Young et al., 2012). Interprofessional and transdisciplinary work foster the development of new approaches to clinical care. This level of interaction leads to new insights in the interpretation of assessments and creative and effective clinical problem solving, leading to successful outcomes. Interprofessional Collaboration The need for collaboration among health care professionals has been a serious concern over many years (Bainbridge et al., 2010; Dumez, 2011; Petri, 2010; World Health Organization, 1978). Efforts to transform health care systems around the world to improve the reliability of care, safety, quality, efficiency, and cost-effectiveness will not be successful unless clinicians, teams, and administrators undertake the important collaborative work leading to transformation. Several phenomena have coalesced to bring the struggles to attain interprofessional collaboration to a critical point. The IOM report on quality and safety in the late 1990s (IOM, Committee on Quality Health Care in America, 2001) identified shortages of providers, especially in primary care, and the need for team approaches through community-based care, accountable care organizations, and nursemanaged clinics. In addition, the 2011 IOM report The Future of Nursing urged teamwork among health care providers. These initiatives have all led to a continuing focus on the need to foster interpersonal and interprofessional competency for all health care providers. The pressing need for collaboration among health care professionals led to the development of specific interprofessional competencies in 2011 (ACA, 2010; Canadian Interprofessional Health Collaborative [CIHC], 2010; IPEC, 2011). A paradox of the contemporary health care systems of several countries is that there are incentives and disincentives for members of different disciplines, work groups, and organizations to collaborate. Incentives and disincentives may be equally powerful so that motivation to collaborate can be diminished or eliminated by a compelling counterforce (Fig. 12.1) (Young et al., 2012). An understanding of this paradox can help APRNs and their colleagues approach opportunities for collaboration strategically and build and sustain clinical environments that support collaboration. Numerous clinical initiatives aimed at improving quality and safety, the need to eliminate health care disparities, and an increasing proportion of health care professionals other than physicians underscore that interprofessional collaboration at the educational, clinical, and institutional levels is essential in the current health care marketplace (IOM, 2011; Pohl, Hanson, Newland, & Cronenwett, 2010; Schmitt, 2011). The ability to collaborate is essential for APRNs to implement interprofessional practice models and analyze complex health problems in an interactive environment (Cronenwett & Dzau, 2010; IOM, 2011; Pohl et al., 2010). FIG 12.1 Driving and restraining forces for interprofessional practice, research, and education. (From Young, H. M., Siegel, E. O., McCormick, W. C., Fulmer, T., Harootyan, L. K., & Dorr, D. A. [2012]. Interdisciplinary collaboration in geriatrics: Advancing health for older adults. Nursing Outlook, 59, 243–250.) Characteristics of Effective Collaboration The definition of collaboration invites exploration of the characteristics that make up a successful collaborative relationship. Personal and setting-specific attributes are pivotal to successful collaborations. Some characteristics of collaboration have long been recognized, but clinicians and organizations have often resisted adopting the necessary philosophy, commitment, and behaviors. Steele's early analysis (1986) of collaboration among NPs and physicians revealed several characteristics—mutual trust and respect, an understanding and acceptance of each other's disciplines, positive self-image, equivalent professional maturity arising from education and experience, recognition that the partners are not substitutes for each other, and a willingness to negotiate. Petri (2010) and Hughes and Mackenzie (1990) have outlined four characteristics of NP- physician collaboration: collegiality, communication, goal sharing, and task interdependence. Spross (1989) described three essential elements of collaboration: a common purpose, diverse and complementary professional knowledge and skills, and effective communication processes. These early works highlight the core elements necessary for collaboration that are listed in Box 12.2. Box 12.2 Essential Characteristics of Collaboration • Clinical competence and accountability • Common purpose • Interpersonal competence and effective communication • Trust • Mutual respect • Recognition and valuing of diverse, complementary knowledge and skills • Humor Collaboration requires clinical competence, common purpose, and effective interpersonal and communication skills or, at a minimum, a willingness to learn them. Trust, mutual respect, and valuing each other's knowledge and skills are equally important but develop over time. For these characteristics to develop, prospective partners must approach encounters with a willingness to trust, a commitment to respect each other, and the assumption that the other's knowledge and skills are valuable. In one sense, these characteristics are prerequisites; however, they are fully realized only after many constructive and productive interactions. Finally, a sense of humor among team members often serves many functions in helping team members stay committed to each other's collaborative practice. Clinical Competence and Accountability Clinical competence is perhaps the most fundamental characteristic underlying a successful collaborative experience among clinicians; without it, the trust and desire needed to work together are not possible. Trust and respect are built on the assurance that each member is able to carry out his or her role, function in a competent manner, and be accountable for practice. Clinical competence is a critical element of collaboration and has been supported by research (Bosque, 2011), yet stereotyped views of nursing and medical practice may interfere with collaborative efforts. These stereotypes may include physicians as having ultimate responsibility and nurses as having little responsibility. Mutual trust and respect develop when collaborating clinicians can rely on each other's clinical competency. Partners share decisionmaking power because they recognize that leadership is problem based, not team or role based. Contemporary leadership shifts among partners in a departure from the traditional “captain of the team” approach. Thus the person with the most expertise, interest, talent, or willingness to lead can respond to the particular demands of the situation or problem. The accountable care organization and medical home concepts are excellent examples of how this approach works. The trust and respect among collaborators are such that they can count on the satisfactory resolution of the problem, even when they know as individuals that they might have approached the issue differently. This openness to shared leadership and alternative solutions allows partners to learn from each other. Collaboration offers APRNs and physicians opportunities to model their varied assessment and intervention strategies, which fosters mutual learning and appreciation for the contributions of each to the care of patients and families. However, the environments in which APRN students and new graduates work must support them as they learn and mature clinically. Trust and assertiveness seem to act reciprocally in collaboration; as trust grows, so does the ability to communicate in difficult situations. Responding assertively in situations of risk and keeping the focus on the patient's welfare can enhance trust. Respect for others' practice and knowledge is key to successful collaboration because it enhances shared decision making. Respect extends to acknowledgment and appreciation for each other's time and competing commitments. Being accountable for practice enhances collaboration. APRNs model full partnership on caregiving teams when they share planning, decision making, problem solving, and goal setting for patient care (Clausen et al., 2012; IPEC, 2011). Common Purpose Collaboration is predicated on the notion of having a common purpose (Murray-Davis, Marshall, Gordon, 2011; Petri, 2010). Even if partners have not discussed the purposes and goals of their interactions, the organizations in which they work usually have an explicit mission and goals. Goals can be the starting point for identifying the purposes of clinical collaboration. Common purposes may range from ensuring that an underserved patient gains access to preventive services, such as mammography, to a more ambitious quality improvement agenda to improve the management of heart failure patients across settings. One of the paradoxes of collaboration is that the partners are autonomous (self-governing, accountable) but interdependent, reflecting a reciprocal reliance on each other for support in carrying out their responsibilities. Recognizing their interdependence, team members can combine their individual skills to synthesize care plans that are more complex and comprehensive than what they could have created working alone. Like other characteristics, the common purpose that initially brought partners together may change over time. The situation that brought two clinicians together may become secondary to the deep personal commitment to work together in ways that improve patient care and are interpersonally and professionally satisfying. In addition to a common purpose, partners who are guided by a shared vision of the possibilities inherent in collaboration, believe in the value of collaboration, and are committed to achieving the relationship's potential (Young et al., 2012) will be most able to develop transdisciplinary and interprofessional collaboration. Developing a shared vision permits partners to value each other's ideas, opinions, and actions. Interpersonal Competence and Effective Communication Interpersonal competence is the ability to communicate effectively with colleagues in a variety of situations, including uncomplicated routine interactions, disagreements, unique cultural value conflicts, and stressful situations. The key to demonstrating interpersonal competence is the ability to communicate openly, clearly, and convincingly. Oral and written communications share some commonalities but require different abilities. The concept of transparency is important. The IOM's Crossing the Quality Chasm lists transparency as one of the rules for the 21st century health care system (IOM, Committee on Quality Health Care in America, 2001). The term transparency can be defined as the honest and open sharing of information and ideas. It includes open communication among parties and not pretending everything is fine when it is not. Transparent communications are closely linked to accountability; transparency engenders trust and thus is an underlying requisite for collaboration. After clinical competence, interpersonal competence and effective communication may be the most important characteristics needed for APRNs to establish collaborative relationships. Assertiveness is a key element of interpersonal competence needed by all APRNs. Assertiveness may be a challenge for women in some cultures and will have to be carefully exhibited. A range of qualities may be required for APRNs to be able to do the following: take risks; discuss disagreements in clinical judgment and agree to criteria for resolving such conflicts; be able to avoid a near-miss clinical situation, such as an error in prescribing or interpretation of clinical data; and admit that a mistake, miscommunication, or oversight has happened. Assertiveness is not sufficient in certain situations and environments and, in these cases, courage will be required to confront the problem. Recognizing and Valuing Diverse, Complementary Culture, Knowledge, and Skills High-quality patient care requires an interpersonal belief that the complementary knowledge other team members have will enhance one's own personal plan for patient care. Appreciation for the diverse and complementary knowledge each party brings to the work, commitment to quality and patient-centeredness, and willingness to invest in the partnership or team are all necessary for collaboration to become the normative process in team interactions. A lack of knowledge about another's discipline is a barrier to developing effective teamwork (Dumez, 2011). Team members must recognize and value the overlapping and diverse skills and knowledge that each discipline brings to the team (CIHC, 2010; IPEC, 2011) so that mutual trust and respect can develop and deepen over time. Partners observe that patients benefit from their combined talents and efforts. They come to depend on each other to use good clinical judgment and to take appropriate actions. Initially, collaborators have limited knowledge of each other as individuals and as professionals; collaboration is a conscious, learned behavior that improves as team members learn to value and respect one another's practice and expertise (IPEC, 2011). The first step is to recognize these differing contributions. For example, medicine and nursing, although overlapping disciplines, are culturally distinct and have diverse goals for patient care. In many cases, they complement each other. These complementarities also extend to other disciplines. Collaboration is built on the respect and valuing of the contributions of each profession to the common goal of optimal health care delivery. Humor Humor can serve as an important aspect of the collaborative process. Despite the serious nature of nurses' work, there's always room for levity somewhere. And, perhaps, serious work is where humor is needed the most (Rosenblatt & Davis, 2009). In collaborative practice, humor serves to decrease defensiveness, invite openness, relieve tension, and deflect anger. Humor helps individuals keep perspective and acknowledge the lack of perfection, and it sets the tone for trust and acceptance among colleagues so that difficult situations can be reframed. Ciesielka, Conway, Penrose, and Risco (2005) suggested that humor is essential to successful collaboration because it is a bridge to different backgrounds. The use of humor helps defuse the need for persons to argue their own point of view and allows them to refocus on how they can work together to meet common goals. APRN students can be encouraged to observe how humor is used by preceptors and colleagues and identify those uses that seem effective for improving communication and defusing conflict situations. Humor can be a challenge at times, however. Humor is a complex cognitive experience usually designed to cause laughter, but these experiences are often very contextual. This means some attempts at humor can be misinterpreted and invoke a negative response. Care will need to be exercised in using humor to have the desired outcome. Although this list of characteristics of effective collaboration may seem daunting to the novice, a consistent commitment to and practice of collaboration can develop this competency over time in an APRN's practice. Exemplar 12.1 showcases the elements of collaboration in an individual practice. All health professionals need to recognize that investing the time and energy to build these relationships is an important component of clinical practice. The high levels of exchange of ideas and expertise that become possible when all of these characteristics come together is one of the great satisfactions of collaborative practice. Exemplar 12.1 Elements of Collaboration in One Advanced Practice Nurse's Practice Caesar M. is a family nurse practitioner who has a nursing home practice. He also volunteers one evening per week at a free clinic serving people living in poverty and without insurance. Donna is a 35-year-old patient with Crohn's disease; she is married to a welder and they have two children under 10 years of age. Donna had previously worked as a home health aide but had to stop because of her illness. She applied for disability coverage but was denied. The staff at the University Medical Center 75 miles away had initiated intravenous (IV) immune system suppression therapy. Donna was charged $6000 for each treatment, which occurred every 6 weeks. Donna's family income was $22,000 per year. The company that produced the drug approved the free clinic to receive the medication without charge given Donna's family income. This medication had to be reconstituted by a pharmacist under a laminar-flow hood and administered IV over a 2-hour period. Once constituted, the medication was only viable for 4 hours. An additional complicating condition was that Donna had a history of extreme difficulty with IV access via peripheral veins. Caesar knew that only through multiple collaborative arrangements would he be able to assure that Donna would repeatedly receive this needed treatment. The free clinic lacked the necessary supplies or equipment to administer the medication. Caesar's nursing home did have this ability. The administration and the director of nursing at the nursing home were approached and both agreed that this could be done in their facility at no charge to Donna. The next issue was to collaborate on developing a plan to mix the medication. The director of pharmacy at the local critical-access hospital agreed to mix the medications when needed as long as the clinic provided the medication. What was left was obtaining the free services of a surgeon to place an access port through which the IV medication could be administered. One of the volunteer ministers at the free clinic was married to a woman who was the clinic manager for a local surgeon. The surgeon was reluctant to offer the surgical placement for free but he placed the port after substantial pressures from Caesar and the minister's wife/office manager. Now the medication administration dance began. On the day of administration, Donna stopped by the clinic and obtained the medication vial. She took it to the hospital, where the pharmacist reconstituted the drug under the hood and gave the IV bag to Donna. She brought this to the nursing home, where Caesar obtained an IV pump and administered the medication through her port over 2 hours. One year later, the state approved the Medicaid expansion under the Patient Protection and Affordable Care Act. Donna received full insurance to cover her existing condition and she was able to be treated at a facility that could take over all aspects of this care. This is an example of multiple collaborations that might be required to assure treatment. Impact of Collaboration on Patients and Clinicians There is common agreement that collaboration is an important part of clinical practice as an APRN (Bosque, 2011; Young et al., 2012), but some clinicians struggle to be adept at collaboration. Common barriers to interprofessional communication and collaboration include personal values and expectations, personality differences, hierarchy, culture and ethnicity, generational differences, and gender (O'Daniel & Rosenstein, 2008). Patient and provider benefits of collaboration have been documented. Patients are sensitive to the relationships among caregivers and are quick to recognize the lack of respect or trust among their providers. Collaborative relationships with interdisciplinary health care providers can ameliorate some of these negative effects (Remonder, Koch, Link, & Graham, 2010). Successful collaborative practices facilitate patients easily moving among providers as situations dictate. Collaboration requires an ability to transform competitive situations into opportunities for working together that are mutually beneficial and in which all parties can imagine the possibility of creating a win-win situation. In the past, this movement among providers was hampered by a lack of ability for the patient's information to flow with the patient. This is becoming easier with the migration to electronic record systems with patient portals. The impact of APRNs on disease management and care transition interventions indicates that there are positive outcomes for patients. Table 12.1 illustrates the types of patient and provider benefits that have been ascribed to collaboration. Collaboration competencies have been in place for APRNs for several years in the United States, Canada, and Australia (AACN, 2006; Canadian Nurses Association, 2010; NONPF, 2012; Nursing and Midwifery Board of Australia, 2014). TABLE 12.1 Benefits of Collaboration Who Benefits? Benefits Patients Improved quality of care Increased patient satisfaction Lower mortality rate Improved patient outcomes Patients feel more secure, cared for, closer to health care providers Empowers patients and family to become team members Providers Improved trust and respect for caregivers Improved communication and clarity of message Increased sharing of responsibility Increased sharing of expertise Mutually satisfying problem solving Improved communications Increased personal satisfaction Increased quality of professional life Enhanced mutual trust and respect Bridges care-cure dichotomy Expands horizons of providers Avoids redundant care and ensures coverage Empowers providers to influence health policy Adapted from Sullivan, T. J. (1998). Collaboration: A health care imperative (pp. 26–27). New York, NY: McGraw-Hill Health Professionals Division. Evidence That Collaboration Works The United States has been undergoing a number of transitions in health care, and one of these changes has been the introduction of a patient-centered medical home for primary care. This model of care has several elements, but the critical element is collaboration among the health professionals treating the patient (Agency for Healthcare Research and Quality [AHRQ], n.d.). Research on medical homes shows reductions in cost measures and a decrease in overall utilization (Bosque, 2011; Nielsen, Buelt, Patel, & Nichols, 2016). Additional literature, especially from Canada, shows similar findings (CIHC, 2010; Dumont, Briere, Morin, Houle, & Hoko-Fundi, 2010; Rice et al., 2010). Of note, publications that address interdisciplinary collaboration (particularly with physicians) and APRNs specifically have increased with the IPEC development of interprofessional competencies. Important ideas about collaboration from leaders in other disciplines have informed this discussion of collaboration (Bainbridge et al., 2010; Dumez, 2011; Palinkas, Ell, Hansen, Cabassa, & Wells, 2011). One goal of collaboration is to improve the quality of care. Exemplar 12.2 provides an example of one way in which collaboration can accomplish this goal. Exemplar 12.2 Collaboration Works for Patients and Clinicians Dr. C. is a psychiatric clinical nurse specialist at a large tertiary hospital that is part of a rapidly expanding health system. This system includes hospitals, clinics, rehabilitation centers, and home health services and has been participating in new demonstration projects with the US Centers for Medicare and Medicaid Services. These projects are designed to improve the quality of care and to decrease the overall costs of care. New for this health system is changing from a fee-for-service payment system to a global payment for the care received by the patient across settings. In the past, each element of care was paid for as the service was provided and there was little linkage among the various aspects of care. Dr. C has reviewed the past 3 months' data on readmission following discharge from the acute care hospital because this is one of the key quality improvement measures. The new single electronic health record allows providers to follow the patient's care across different sites of care. What Dr. C. determined was that about 70% of the patients who were readmitted to the hospital had depression or anxiety identified during their acute care admission, yet no evidence-based plan of care was provided to deal with these problems. Based on this analysis, Dr. C. decided to build a collaborative pathway to assure that patients who experience depression or anxiety during acute care hospitalization were identified and provided with appropriate treatment. Dr. C. quickly discovered that many providers would be involved in creating and delivering this plan. The first requirement was to assure that all patients received appropriate screening for depression and anxiety. Dr. C. engaged the assistance of social work in helping select the screening tools that were best suited to this situation. Next, Dr. C. met with the manager of the hospitalist program. In this particular hospital, acute care nurse practitioners and internal medicine physicians provide hospitalist services. The nurse manager for critical care was also included because the decision had to be made as to whether the screening would be done by nursing staff or by the hospitalists. The screening tools selected were such that they could be completed easily and accurately by the staff nurse who performs the admission assessment and included in the electronic record. Scores indicating the potential for depression or anxiety in the patient were automatically flagged by the record so that the hospitalists could request a consult by the psychiatric team for further analysis and recommendations for treatment. Evidence-based plans of care were then prescribed as appropriate by either the consultant or the hospitalist. Dr. C. led a formative evaluation as this new approach to screening, diagnosis, and treatment unfolded and was able to make modifications in the plan based on the information provided by all concerned, including the patients and families. Three months after implementation, Dr. C. then conducted a summative evaluation of the program. What was found was that almost all patients had been screened. Those who scored as being at risk for depression or anxiety were placed into a treatment pathway that continued across sites of care, and readmissions to the hospital following discharge were reduced by 50%. Dr. C. continues to monitor the system and to provide written reports to the key collaborators in a timely manner. Research Supporting Interprofessional Collaboration Impact on Health Outcomes NPs have been shown to be effective in managing health conditions in primary care and have been shown to be cost-effective in prior research (Newhouse et al., 2011). The outcomes of NP and CNM care were found to be equal to or in some cases better than outcomes for care provided by physicians alone. CNS care was found to help reduce hospital costs and length of hospital stay. There were insufficient data to evaluate CRNA practices. Competency in collaboration is a part of the clinical requirement for APRN practice and is likely a part of the reason for these findings. Concern has been expressed by some groups that APRNs should not be provided full practice authority as autonomous practitioners. The opposition for APRN autonomy reasons that APRNs will not collaborate if not mandated by regulations. Evidence does not support this contention. Oliver, Pennington, Revelle, and Rantz (2014) reported that NPs who had full practice authority had better health outcomes and decreased hospitalization rates for Medicare and Medicaid beneficiaries compared to those in states that mandated collaboration. Effects of Physician and APRN Collaboration on Costs Burke and O'Grady (2012) reported that group visits carried out by transdisciplinary health care teams are efficacious and hold promise for improved outcomes and better cost containment. Similarly, an integrative review of the impact of transdisciplinary teams on the care of the underserved demonstrated other benefits such as better primary care access and quality for underserved populations (Ruddy & Rhee, 2005). Brooten et al. (2005) have reported the positive effects of APRN and physician collaboration on caring for women with high-risk pregnancies. Jackson et al. (2003) reported that fewer fiscal resources were required when obstetricians and CNMs worked within a collaborative care birth center model. One of the challenges of evaluating cost-effectiveness with respect to clinical collaboration is the ability to measure change over an appropriate time horizon. As the Litaker et al. (2003) study suggested, a 1-year collaborative intervention was enough to change patient behaviors in ways that reduced important clinical markers but was not sufficient to assess and measure the impact of complications and disease-related comorbidities on the disease trajectory over time. The fact that the 1-year intervention was insufficient to sustain the behavior changes that led to the reduced clinical markers supports our conceptualization of collaboration as a process that evolves over time. It is also suggested that our understanding of long-term changes in patient behavior and clinical outcomes may depend on a complete empirical understanding of collaborative processes. Even so, there is evidence that organizationally supported teams, such as rapid response teams, can improve patient outcomes (Scherr, Wilson, Wagner, & Haughian, 2012). In 2010, the Robert Wood Johnson Foundation (RWJF) reported examples of increased quality of life and safety in patients who were cared for by health care professionals who had overcome professional boundaries to work together. Results from such studies will continue to shape our understanding of collaboration and guidance and coaching competencies of APRNs (see Chapter 8). There are many fine examples of collaboration initiatives leading to positive changes in health care and collaborative interactions among the health care disciplines. In 2007, boards of nursing, pharmacy, medicine, occupational therapy, physical therapy, and social work joined in a collaborative effort to assist regulatory bodies and legislators (National Council of State Boards of Nursing [NCSBN], Association of Social Work Boards, Federation of State Boards of Physical Therapy, Federation of State Medical Boards of the United States, National Association of Boards of Pharmacy, and National Board for Certification in Occupational Therapy, 2006). New competencies for education and practice that include collaboration and team work have been developed (IPEC, 2011; NONPF, 2012). Both the IOM Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing (IOM, 2011) and the Josiah Macy Jr. Foundation recommendations for training primary care providers (Cronenwett & Dzau, 2010) include strong recommendations for collaboration among health care professionals. These efforts are encouraging; new positive strides in preparing health professions students for collaborative practice will be fulfilled. Effects of Failure to Collaborate Concerns about the quality of health care began to take on new importance in the United States and elsewhere during the latter part of the 20th century. Some time ago, the Committee on Quality Health Care in America of the IOM (2001) highlighted that patients were not receiving the best care possible and that thousands were dying each year by errors in care delivery. The Institute for Healthcare Improvement (IHI) (2017b) launched their work during this time as well. The problems continue in spite of substantial effort. In 2016 medical error was reported as the third leading cause of death in the United States (Makary & Daniel, 2016). The emerging approaches for improving the quality of health care traced to the work of W. Edwards Deming (1982), who argued that organizations can increase quality and simultaneously reduce costs. The basic assumption of these new approaches to improving health care was that problems were not the fault of any particular individual clinician but were better understood as problems with systems of care delivery. The new idea to decrease errors and improve quality was that collaboration among providers, administrators, and patients would lead to improved quality, decrease injury, decrease costs, and save lives. Failures of collaboration often resulted in harm to patients, including morbidity and mortality. This means that failure to collaborate not only results in less than optimal working conditions for the professionals but also results in serious harm and increased costs of care for the patients (Makary & Daniel, 2016). Balik and colleagues (2011) provide an in-depth analysis of research, studied organizations, and interviewed experts in hospital care to better understand how to improve care to patients and their families during hospitalization. One of the key drivers of quality care was respectful partnerships among providers and administrators. Respectful partnership is one of the critical elements of quality collaboration. These researchers reported that quality care did not occur without respectful partnership. Failure to collaborate results in poor-quality care, increased costs often associated with high staff turnover, and harm to patients. Imperatives for Collaboration Failure to collaborate in health care can result in harm to patients. Therefore, organizations and clinicians have an obligation to collaborate under the moral requirement to do no harm. The effects of collaboration or its failure can be seen in the way that ethical and institutional dilemmas are resolved and how research is conducted. A substantial driving force for collaboration came about as a part of the adoption of the ACA in 2010. There were key elements of this act that required improvements in quality that could only be achieved by interprofessional collaboration. Based on the reality that medical and diagnostic error is a major concern in health care, research and planning are underway at both the AHRQ and through the 2016 Culture of Safety project at the ANA to find a way to provide a culture of safety to undergird patient care (ANA, 2016; Weaver, Dy, Lubomski, & Wilson, 2013). Interventions to promote safety are not easily defined, but safety cultures are described as those in which there is shared commitment to safety and effective teamwork as the highest priority. Although many studies and plans do not attribute lack of collaboration and communication as a direct cause of medical error, collaboration and relationships among caregivers are seen as major forces in alleviating the problem (Manojlovich et al., 2014). Mutual respect, an important component of successful collaboration, ranked high as a predictor of a safe patient environment. Ethical Imperative to Collaborate Collaboration is required to minimize harm from care. Logically, that means that failure to collaborate is an ethical issue. The clinical imperative of APRN roles to collaborate is embedded within the ethical imperative. The IPEC (2011) proposed that all future health professionals assert the values and ethics of interprofessional practice by placing the needs and dignity of patients at the center of health care delivery and included a specific ethics domain and competencies (see Box 12.1). Compassionate and ethical patient care that provides a healing environment requires collaborative working relationships among all the providers, including APRNs (Petri, 2010; Schmitt, 2011). Environments that foster collaboration may also create a more supportive context for addressing ethical issues. Quality patient care requires collaboration because it reinforces commitment to a common goal and reaffirms the central goal of patient welfare. Collaboration enhances shared knowledge because all health care providers repeatedly educate each other about the patient. Collaboration also demonstrates that how care is delivered is as important as who delivers the care. Collaboration is a moral imperative; good patient care requires it. Institutional Imperative to Collaborate The evidence that collaboration works has suggested that there are structural and interpersonal dimensions to collaboration; that is, although institutional policies or standards do not guarantee collaboration, they can establish expectations for collaboration. These institutional expectations can provide a structure that facilitates interpersonal communication and relationship building (ACA, 2010; IOM, 2011). The mutual goals of quality patient care and the ethical imperative to collaborate are at the center of interprofessional efforts to provide care or resolve conflicts in approaches to care for patients. For example, institutions that apply for Magnet status are expected to have a structure in place for interprofessional collaboration as one of the key characteristics (American Nurses' Credentialing Center, 2016). The incentive for hospitals to move to Magnet status has never been higher, with the current emphases on nurse retention, quality, costs, and safety. Institutions that have applied for the American Nurses' Credentialing Center (2016) Magnet credential must demonstrate that they meet five characteristics. These criteria have been associated with the ability to attract and retain nurses. APRNs are usually intimately involved in efforts to seek Magnet status, such as leading quality improvement initiatives, facilitating professional development of staff, and contributing to the establishment of policies and procedures that shape an environment in which effective collaboration can occur. Finally, reducing error and increasing the reliability of care by adopting evidence-based practices constitute another significant institutional imperative to foster collaboration. Improvements that result from such initiatives are often tied to payment for the organization. An example of the institutional imperative to collaborate has been the progression of the Doctor of Nursing Practice (DNP). The national concerns about the quality and safety of health care have informed the development of the DNP and helped form consensus among schools, faculty, and other stakeholders (AACN, 2004). The DNP Essentials (AACN, 2006) set collaboration as a core competency for this degree for APRNs. The document includes numerous mentions of the terms collaboration and collaborative in the competencies required for DNP graduates. Examples that require collaborative competencies include the ability to create change in health care delivery systems, the need to collaborate across settings to enhance population-based health care, and the need for interprofessional collaboration to implement practice guidelines and peer review processes (AACN, 2006). Current competencies for all APRN groups include competencies based on high-level communication and interprofessional practice skills. Research Imperative to Study Collaboration Schmitt (2011) suggested that collaboration be examined as an intermediate outcome when health care is evaluated. In a review of the literature, Schmitt cited a number of challenges faced by health services researchers in trying to understand collaboration and its impact on outcomes. Methodologic challenges include the need for more robust, well-designed studies, including clinical trials, to provide more conclusive evidence about the impact of collaboration on patient outcomes. In addition, sample selection, measurement of collaboration, and outcome measurement pose dilemmas for those interested in studying the phenomenon. A major limitation of existing knowledge is that much of it comes from hospital-based practice and, according to Schmitt, studies of collaboration and its outcomes are underdeveloped. Institutional imperatives to collaborate and the research imperative to study collaboration are becoming more closely aligned. For example, the AHRQ has become an important resource for funding and disseminating the results of research on quality improvement, patient safety, adoption of evidence-based practices (EBPs), and other issues associated with the delivery of safe and reliable health care. Manojlovich et al. (2014) stressed the need to build a better safety climate through improved interprofessional collaboration. In addition, the National Institutes of Health Common Fund continues to expect collaboration among clinical investigators. Drenning (2006) has urged collaboration among nurses, APRNs, and nurse researchers to understand and implement EBP changes likely to improve patient care. The National Center for Interprofessional Practice and Education (2017) reports that it supports over 80 research projects across the United States to focus on interprofessional practice and education. The projects are evaluating how interprofessional practice can be used effectively in different clinical and learning environments. The focus is on clinical practice and community engagement through onsite training and classroom learning. Collaboration among providers with different perspectives results in a creative and multidimensional intelligence that is emotionally rewarding because patients do better and clinicians derive personal and professional gratification from this work. This has implications for APRNs, administrators, clinicians, researchers, and others. APRNs and administrative and clinical colleagues need to assess the collaborative climate, determine facilitators and barriers, and work together to strengthen relationships while building an organizational culture that values collaboration. Researchers must help APRNs and administrators understand the structures and processes associated with collaboration and the extent to which collaboration affects patient and utilization outcomes. Context of Collaboration in Contemporary Health Care The pressures on APRNs and others to improve quality, work more efficiently, and allow others to be involved in decisions about patient care could be expected to foster collaboration among clinicians. Paradoxically, these same factors may undermine collaboration. As APRNs practice autonomously and collaboratively, other clinicians have experienced concerns including the increasing supply of APRN providers, which can encroach on the autonomy of others and their willingness to collaborate. Pressures on some physicians may generate concern about relinquishing authority and power and fears that may cause individuals to withdraw from or sabotage efforts to collaborate. Moreover, collaboration can also take more up front time, which may appear to decrease efficiency but improves outcomes and saves time in the long run. Thus the transition to a presumably more effective, accessible, and efficient health care system may actually undermine collaboration In addition, confusion about scope of practice can be damaging to collaboration for all involved. Other independent practitioners may ask themselves the following (Safriet, 2002): • What's in it for me to collaborate? • What areas of my work do I get to expand because other providers can do things that I have traditionally done? APRNs may be uncertain about how to proceed with collaboration, for example, when they are asked to assume responsibility for a new skill such as performing an invasive procedure. The reality is that regulatory initiatives and payment structures are rearranging collaborative relationships frequently. These changes are often at the heart of the tension associated with collaboration among players as the roles and boundaries of disciplines have blurred and expanded. Incentives and Opportunities for Collaboration Efforts to reduce costs and improve quality of health care provide APRNs, other clinicians, and administrators with common goals toward which to work and with opportunities for learning from each other. National interdisciplinary guidelines and standards of care are intended to reduce unwarranted and often expensive variations in health care. Many guidelines specify interdisciplinary collaboration as a critical component of effective care. Standards and guidelines developed and agreed on by interdisciplinary groups, whether at the local (office or institution), national, or international level, offer a sound starting point for jointly determining patient care goals, processes, and outcomes. Accreditation activities offer another opportunity to build collaborative relationships. The Joint Commission requires documentation that demonstrates collaborative, interdisciplinary practice to help providers develop stronger interdisciplinary approaches to care. The need for a highly coordinated system of chronic care management led the Health Sciences Institute to promulgate interdisciplinary competencies. The goals for chronic illness care, which include promoting health and preventing disease, managing disease and disease impacts, and promoting consumer independence and life quality, are centered on a model in which all players are valued for their contributions and collaborative effort. The move toward a more community-based, health promotion and disease prevention model of care has also been creating new opportunities for collaborative practice in primary care (Bodenheimer & Grumbach, 2012). The use of telehealth and electronic health records also offers creative opportunities for interaction. For these systems to work, APRNs and other clinicians need to be involved in selecting, piloting, modifying, and implementing new technologies. From the selection of vendors to full deployment of the technology, the adoption of new technologies offers opportunities for clinicians to develop collaborative learning communities. In the current global market, innovative new alliances among advanced practice nursing groups and physician groups need to be developed and nurtured (McCaffrey et al., 2010; Young et al., 2012). Barriers to Collaboration Implementing effective collaborative professional relationships in the workplace can be challenging. Barriers to collaboration exist and can be characterized as professional, sociocultural, organizational, and regulatory. Part of the challenge is that team members see themselves primarily as representatives of their own discipline rather than as members of a collaborative team. Disciplinary Barriers The way health professional education is conducted in the United States has long been a barrier to successful collaboration. Each profession is a culture with its own values, knowledge, rules, and norms, and education programs reflect this culture. Additionally, education programs are frequently conducted at different types of colleges and universities where there may be little opportunity for shared learning. The basic epistemology that underlies each type of profession may be unique and, at times, may conflict with that of other professions. This leads to differences in understanding what constitutes truth, goals of practice, and expected outcomes even when there is joint practice. One profession may firmly believe that it is the only one that has the whole picture for the patient, as evidenced by the continuing efforts to place CRNAs under physician supervision (see Chapter 18). Similar issues are seen at times for NPs and CNMs. Pharmacists may believe that they are the single authority for questions concerning medication. In an evaluation of the Hartford Foundation initiative to strengthen interdisciplinary team training in geriatrics (Reuben et al., 2004), faculty and students in advanced practice nursing, medicine, and social work were found to be influenced by disciplinary attitudes and cultural factors that were obstacles to teamwork, a phenomenon the authors termed disciplinary split. They observed that disciplinary heritage and a differential willingness to participate in teamwork characterized disciplinary split and constituted an obstacle to implementing effective interdisciplinary teamwork in geriatrics training. There are few opportunities for interdisciplinary education as health care providers learn their professions. The RWJF Partnerships for Training initiative (Rice et al., 2010; RWJF, 2003; Young et al., 2012) identified many of the stresses inherent in building and sustaining interprofessional academic-community partnerships. Stresses encountered by participants as they developed partnerships centered on money, differing agendas, systems that were not integrated, varying philosophies, and long-held beliefs about how things should be done. Collaboration is often easier to implement and maintain at the community grassroots level than at the professional organizational level. Although collaboration happens daily among practicing clinicians, collaboration may not exist at the national level, impeding efforts to move toward a coordinated health care system. The dated positions espoused by some policymakers from all disciplines may be based on stereotyped beliefs about disciplinary roles and responsibilities, rather than reflecting consideration of the issues or what is best for patients. These factors make it increasingly important for APRNs and other clinicians practicing at local levels who have learned the art of collaboration to take an active role in bringing their perspectives and experiences to policymaking at institutional, community, state, and national levels to foster collaboration. A broader statutory definition of professional autonomy for APRNs than what is found in many states is necessary if the more complex autonomy of interdependent collaborators is to be exercised effectively (Lugo, O'Grady, Hodnicki, & Hanson, 2007; Safriet, 2002). Despite these existing challenges to collaboration, there is evidence of progress. The US Preventive Services Task Force, which is part of the federal AHRQ, is made up of an interdisciplinary group of providers and researchers who develop, disperse, and revise evidence-based recommendations on screening and prevention for a variety of health care concerns (US Preventive Services Task Force, 2012). Ineffective Communication and Team Dysfunction Communication styles may also be a barrier to collaboration. Dysfunctional styles of interactions among health care professionals that particularly undermine collaboration include being difficult, bullying, or abusive (Anderson, 2011). The term disruptive behavior has been used to include these and other intimidating behaviors. Clinicians whose behavior is disruptive display arrogance, rudeness, and poor communication (Longo & Smith, 2011; Saxton, Hines, & Enriquez, 2009). APRNs have a responsibility to recognize disruptive behaviors as risks to collaboration and safe patient care and to develop a repertoire of interpersonal and system strategies with which to address these behaviors directly and promptly. Lencioni (2005), a business consultant on team effectiveness, has proposed a model of team dysfunction that has a practical use by APRNs. In this model, the first four of the five dysfunctions reflect the absence of key components of our definition of collaboration: absence of trust, fear of conflict, lack of commitment, and avoidance of accountability. The fifth dysfunction, inattention to results, is consistent with the observation that efforts within health care to improve safety, reliability, and quality represent an opportunity to foster teamwork and collaboration by examining the processes and outcomes of care, attending to results. Sociocultural Issues Tradition, role, and gender stereotypes are obstacles to collaboration (Rafferty, Ball, & Aiken, 2001). Safriet (1992) has suggested that the field of medicine staked out broad professional territory early on and considers any movement into this turf by other clinicians, at any level, to be unacceptable. This bias can lead to challenges to successful collaboration. Nursing remains a predominantly female profession and, despite the influx of women into medicine, pharmacy, and dentistry, gender role stereotypes still exist and affect collaboration. Gender stereotypes dominate images of staff nurses in the media and how APRNs are commonly portrayed on television. However, the rules are changing as all of health care becomes increasingly female. Stereotypical images of APRNs influence how they are viewed by consumers, and this can be positive. Australia has only had very limited experience with NPs in primary care. Parker et al. (2012) asked consumers in five Australian states their thoughts about receiving their primary care from NPs. Almost none of the consumers had any knowledge about what NPs were. The consumers indicated that they highly valued registered nurses and that NPs would be very acceptable for their primary care since they were registered nurses who could also prescribe drugs and authorize referrals. Organizational Barriers Competitive situations arise that can interfere with collaboration. The patchwork of US federal and state policies, rules, and regulations along with organizational rules and policies concerning APRN practice can make collaboration difficult. This set of rules can also lead to unproductive competition among clinicians. For example, the intent of Medicare billing requirements was to foster cooperation among clinicians, but they also discourage collaborative relations between health care providers and may actually serve as disincentives. “Incident-to” billing (see Chapter 21) requires that patient care services provided by APRNs be directly supervised by physicians and offers reimbursement inequities, severely hampering a collaborative environment (Centers for Medicare and Medicaid Services, 2016). Regulatory Barriers Legislation and regulations pose a number of barriers to the implementation of collaborative roles. In the early days of advanced practice nursing, the overlap in APRNs' and physicians' scopes of practice was often addressed by requiring physician supervision of aspects of APRN practice. An outcome of this early requirement was that physician supervision often appeared in advanced practice nursing literature on collaboration and in state practice acts and regulations. In the past 30 years, there has been a slow but steady movement away from references to protocols and language requiring physician supervision toward emphasizing consultation, collaboration, peer review, and use of referral (Lugo et al., 2007). APRN practice based on joint purposes and the public interest is more likely to foster collaboration between the professions (ACA, 2010; IOM, 2011; Safriet, 2002). A supervision requirement precludes the development of a collaborative relationship and physicians cannot supervise advanced practice nurses. Eliminating regulatory barriers to full practice authority has been one of the pillars of the IOM work in The Future of Nursing (2011). Substantial work continues to remove these and other barriers for APRNs throughout the United States. Similar efforts are taking place in other countries as they discover that creating artificial barriers to full practice is counter to national goals of access to high-quality care for their people (Carter, Owen-Williams, & Della, 2015). Adopting a multistate licensure compact for APRNs has become important to ensure that collaboration and continuity of care can occur (NCSBN, 2017). Consumers are consulting quality scorecards, licensing boards, websites, blogs, and other Internet resources to identify agencies and individual clinicians who provide the best health care. Opportunities to create collaborative relationships can be lost during rapid changes in health care (Remonder et al., 2010; Young et al., 2012). Furthermore, nurses and other clinicians who are confronting their own professional concerns may not fully appreciate the stresses that others experience in today's volatile market. This factor is a serious deterrent to collaborative relationships. Collaboration within the APRN nursing community is also problematic at times. Overall, there are four dimensions of APRN regulation—licensure, accreditation, certification, and education. Often, language and policy barriers make it difficult for the groups responsible for each of these to collaborate. These groups have created a collaborative network that allows them to match their individual organizational priorities to the priorities for APRNs overall. Exemplar 12.3 describes this effort and illustrates how an initial failure to collaborate can turn into a win-win situation for all involved. Exemplar 12.3 A Long-Term Collaboration for the Education and Regulation of Advanced Practice Registered Nurses (APRNs) The implementation of the Consensus Model for APRN Regulation is an exemplary illustration of how collaboration works to accomplish a challenging component of advanced practice nursing. In the United States, the board of nursing in each state has the responsibility and authority to regulate nursing at the beginning and advanced levels. In the 1990s there was a rapid proliferation of educational programs and certification processes for postgraduate education, particularly for nurse practitioners. The National Council of State Boards of Nursing was confronted with an array of different and potentially confusing sets of credentials that varied from state to state. There had been a long history of practice by nurse anesthetists and nurse-midwives but these roles were regulated by the nursing board in some states and by the medical board in others. Multiple new nurse practitioner programs were developing and often in narrow areas such as pediatric oncology or palliative care. Emerging from what had become confusing regulation was the creation of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. Over 70 nursing organizations engaged in high-level collaboration to bring the consensus process for APRN regulation into successful implementation. Currently, interacting through a social media entity entitled LACE, nursing legislators, accreditors, certifiers, and educators accomplish the difficult and challenging work of implementing the Consensus Model for APRN Regulation across all states. As implementation of this model evolves, a more seamless practice environment for APRNs exists across all states. In most cases, the state legislatures and the governors must pass legislation to meet the new standards for education and certification as well as recognize independent practice and independent prescribing by all four roles of APRNs. Progress is being made each year to achieve this goal of common recognition. Prior to this work, there were very few examples of nationwide collaboration among APRN nurse associations, educators, certifiers, accreditors, and the member boards of nursing. Through this important collaboration, this work continues today with regularly scheduled meetings and recognition of the consensus process. Processes Associated With Effective Collaboration Recurring Interactions A trusting and collaborative relationship develops over time and depends on recurring, meaningful interactions (Alberto & Herth, 2009). Development of trust particularly takes place over time. This means that collaborative relationships are difficult to develop in organizations in which there is a high staff turnover or frequent rotation of clinicians, such as with house staff physicians. A series of less-complicated interactions that have been clinical or personal will contribute to the development of trust in collaborative relationships. Team members need recurring interactions to acquire an understanding of each other's backgrounds, roles, and functions and develop patterns of interaction that are constructive, productive, and supportive. Projects focused on quality and outcomes of care that involve joint collection and analysis of data build collegiality and foster collaboration. Membership on interdisciplinary committees, such as pharmacy and therapeutics, performance improvement, institutional review boards, ethics, and others with a patient care focus, also foster communication and collegiality. Effective Conflict Negotiation and Resolution Skills Conflict will arise as individuals, teams, and organizations work more closely together on their shared goals. APRNs need to have some general approaches to conflict negotiation and resolution. Box 12.3 lists some key conflict resolution skills (Conflict Resolution Network, 2016). Box 12.3 Conflict Resolution Network's 12 Skills Summary • Win-win approach (How can we solve this as partners rather than opponents?) • Creative response (Transform problems into creative opportunities.) • Empathy (Develop communication tools to build rapport; use listening to clarify understanding.) • Appropriate assertiveness (Apply strategies to attack the problem, not the person.) • Cooperative power (Eliminate “power over” to build “power with” others.) • Managing emotions (Express fear, anger, hurt, and frustration wisely to effect change.) • Willingness to resolve (Name personal issues that cloud the picture.) • Mapping the conflict (Define the issues needed to chart common needs and concerns.) • Development of options (Design creative solutions together.) • Introduction to negotiation (Plan and apply effective strategies to reach agreement.) • Introduction to mediation (Help conflicting parties to move toward solutions.) • Broadening perspectives (Evaluate the problem in the broader context.) Adapted from Conflict Resolution Network. (2016). 12 Skills summary: Conflict resolution skills. Retrieved from http://www.crnhq.org/12-Skills-Summary.aspx?rw=c. Partnering and Team Building Health care leaders are examining ways to improve the functioning of teams (Bosque, 2011; IPEC, 2011). Effective models of teamwork have been used in subspecialties in psychology and health care. APRNs can draw on the lessons learned in these fields to improve team functioning. Some of the processes that have been associated with effective team building and conflict negotiation are listed in Box 12.3. Partnering is often a long-term process over several years with different partners, as illustrated in Exemplar 12.3. Implementing Collaboration There are times when APRNs may feel as though they are the only ones with an active commitment to collaboration. Collaboration may be the most difficult competency to accomplish because it is mediated by social processes such as attitudinal and cultural factors that are ingrained in their professions or in society. Efforts to change the environment to one that is more collaborative involve proving oneself over and over and challenging colleagues' behaviors that restrain attempts to work together. These intrapersonal demands, along with clinical demands, can be exhausting. Therefore APRNs need to evaluate the potential for collaboration when seeking career opportunities. Questions about how clinicians work together, the degree of hierarchy, the interpersonal climate, and organizational structures that support collaboration should be a high priority. A realistic appraisal of collaboration is needed to determine whether APRNs can provide the standards and quality of care that are characteristic of advanced practice nursing and whether they can expect a reasonable level of job satisfaction. Assessment of Personal and Environmental Factors APRNs bring many personal attributes to a professional partnership. Assessment of their current attributes compared to the characteristics of collaboration listed in Box 12.4 can help beginning APRNs to determine the areas most in need of development. Box 12.4 Personal Strengths and Weaknesses Strategies • Am I clear about my role in the partnership? • What values do I bring to the relationship? • What do I expect to gain or lose by collaborating? • What do others expect of me? • Do I feel good about my contribution to the team? • Do I feel self-confident and competent in the collaborative relationship? • Are there anxieties causing repeated friction that have not been addressed? • Has serious thought been given to the boundaries of the collaborative relationship? Adapted from Rider, E. (2002). Twelve strategies for effective communication and collaboration in medical teams. BMJ Clinical Research, 325, S45. Covey (1989) offered a perspective on moving toward a higher level of interdependence with colleagues. He portrayed interdependence as a higher level of performance than independence. Only individuals who have gained competence and confidence in their own expertise are able to move beyond autonomy and independence toward the higher synergistic level of collaboration. Collaboration appears to have the same meaning as interdependence in Covey's work. This view is provocative when one considers the hierarchical context that often frames clinical collaboration. The notion that interdependence is the higher level of performance is supported in the evolution of advanced practice nursing. A number of clinical specialties are evolving to such a stage as disciplines mature and identify a shared interprofessional component to their work. For example, in the specialty of diabetes, advanced diabetes management involves interprofessional collaboration (Gucciardi, Espin, Morganti, & Dorado, 2016) and is recognized by a certification examination open to a number of disciplines (see Chapter 5). Teams are expected to collaborate with patients and their families in addition to each other. This collaborative relationship can be problematic for clinicians and/or patients. Saxton et al. (2009) suggested that when patients are abrasive or ill-equipped to deal with conflict, clinicians should remember to treat these patients with dignity and respect, even when disagreeing with them, and remember that a patient is more than his or her illness. In addition, illness can interfere with or diminish a patient's normal or effective communication skills. Crocker and Johnson (2006) found that patients may assert themselves by honoring their body's wisdom and firing caregivers whom they view as not compassionate. Self-assessment is one important component to consider when embarking on a new professional relationship or evaluating the success or failure of current or potential collaborative relationships. The self-directed questions in Box 12.4 may help individuals identify personal strengths and weaknesses. APRNs should also consider contextual factors in the systems in which they practice. Administrative leadership plays a key role in the development of collaborative relationships among organizational members. Administrators who support team and interprofessional administrative models, and who are themselves good communicators, can do a great deal to increase the momentum of new collaborations. The common vision of quality patient care and provider satisfaction makes collaboration a worthy goal for APRNs and nursing administrators. Global interactions require high levels of individual and organizational collaboration beyond what can be envisioned. APRNs who recognize the need for global participation and collaboration at the personal, organizational, and systems levels are more likely to be successful. Strategies for Successful Collaboration Individual Strategies Box 12.5 lists strategies that promote collaboration (Rider, 2002). APRNs can examine their interactions for opportunities to implement these ideas and strengthen their interpersonal competence. Box 12.5 Strategies to Promote Effective Communication and Collaboration • Be respectful and professional. • Listen intently. • Understand the other person's viewpoint before expressing your opinion. • Model an attitude of collaboration, and expect it. • Identify the bottom line. • Decide what is negotiable and non-negotiable. • Acknowledge the other person's thoughts and feelings. • Pay attention to your own ideas and what you have to offer to the group. • Be cooperative without losing integrity. • Be direct. • Identify common, shared goals, and concerns. • State your feelings using “I” statements. • Do not take things personally. • Learn to say “I was wrong” or “You could be right.” • Do not feel pressure to agree instantly. • Think about possible solutions before meeting and be willing to adapt if a more creative alternative is presented. • Think of conflict negotiation and resolution as a helical process, not a linear one; recognize that negotiation may occur over several interactions. Adapted from Rider, E. (2002). Twelve strategies for effective communication and collaboration in medical teams. BMJ Clinical Research, 325, S45. One strategy is for APRNs to promote their exemplary nursing practices to help other health professionals and consumers better understand the strengths of APRNs as health care providers (Pohl et al., 2010). Participating in interdisciplinary quality improvement initiatives and developing and evaluating EBP guidelines (see Chapter 10) are other ways to engage with colleagues within and across disciplines. One way to share excellence in practice in grand rounds or a team conference is to include the opportunity for each care team member to describe her or his own decision making about patients and suggest new strategies for care to the team. Team Strategies The development of effective teams was one of the IOM's recommendations for improving health care quality (ACA, 2010). Lencioni's field guide (2005) provides activities aimed at helping team members overcome the team dysfunctions described earlier, noting that there are two important questions team members must ask themselves: • Are we really a team? • Are we ready to do the heavy lifting that will be required to become a team? A group of collaborators will be able to use the field guide to their advantage if they can respond affirmatively to both questions. The activities are aimed at helping teams address each of the five dysfunctions by helping them build trust, master conflict, achieve commitment, embrace accountability, and focus on results. One serious challenge to collaboration is team members who are not interested in developing collaborative teams. In this type of situation, APRNs must step up and operate from a stance and expectation of collaboration; that is, APRNs should model collaboration in all interactions and expect the same from all other members of the team. Building a group of like-minded colleagues can also increase the momentum toward collaboration as the expected style of interaction within a team. APRNs should understand that collaboration is only beginning to be taught in health professions schools. Consequently, they must be prepared to teach this process to others. A recent concept is the idea of a group visit by a collaborative group of providers. The group visit can be understood as an extended office visit during which not just physical and medical needs are met, but educational, psychological, and social concerns are also addressed by a collaborative group of caregivers invested in caring for the patient (Burke & O'Grady, 2012; Young et al., 2012). A suggested starting point might include consideration of ways to plan ahead before starting collaborative group visits, how to let patients know about the new change, who needs to be part of the collaborative provider group, who does what, and an agenda for the visit (Bodenheimer & Grumbach, 2012). An example of a group visit practice that includes an NP, a CNS, and a CNM is “Centering Pregnancy: A New Program for Adolescent Prenatal Care” (Moeller, Vezeau, & Carr, 2007). The great significance of the group visit is the inclusion of the patient as part of the group and the cost-effective use of resources to address multiple aspects of the patient's care. Working together on joint projects is an excellent way to facilitate collaboration. Collaborative research and scholarly writing projects, as well as community service projects that tap into the strengths of various members, demonstrate the benefits of collaboration. These strategies move across lines from personal life to organizational settings and from education to practice arenas. New models that foster team care are needed in primary care and within specialty practice in all settings. More importantly, collaboratively developed practice guidelines improve communication and clarify clinicians' roles in patient treatment (Cooper, 2007; US Preventive Services Task Force, 2012). Organizational Strategies The numerous initiatives to improve safety and quality that have evolved from the IOM reports can help health administrators and leaders create organizational structures that facilitate collaboration while attending to important quality and safety goals. The IHI's white papers, The Joint Commission and Magnet requirements for evidence of interdisciplinary collaboration in patient care, toolkits for interdisciplinary education, and clinical and organizational toolkits to facilitate the adoption of EBP guidelines (e.g., from the Registered Nurses Association of Ontario [http://rnao.ca/bpg]) are available. These toolkits often include assessments that can be done to identify the location of the barriers and the opportunities for improvement. APRNs and other clinical colleagues and leaders can use these assessments to develop strategic plans for improving the collaborative environment. Clinicians may need professional development to enable them to collaborate depending on the results of the assessment. Organizational leaders must take seriously reports of disruptive behavior and take action to eliminate this behavior. Kinnaman and Bleich (2004) have observed that collaboration requires more resources and suggested that the type of problem-solving behavior should be matched to the degree of complexity and uncertainty inherent in the problem. APRNs will find it useful to pay attention to the costs in time, money, resources, and patient outcomes of collaborating and not collaborating. Documenting positive and negative patient and institutional outcomes of collaboration or its absence can contribute to identifying which clinical resources are needed to achieve clinical and institutional goals. One strategy that fosters successful collaboration is a move toward interdisciplinary education programs that allow for face-to-face interaction and joint problem solving among health science students (Alberto & Herth, 2009; Bainbridge et al., 2010; Petri, 2010). Definitive changes in the structure of clinical education and sequencing of content will be required. This will be a difficult task given the entrenched bureaucracies involved and will require stronger interactions among education programs. Health care providers need to be learning about health policy issues from a perspective that offers broad solutions. Faculty across programs need to be evaluating and treating patients and supervising students together. Joint appointments among the faculty of different professions provide the opportunities to model advanced practice nursing care and build rapport. Health professional organizations have endorsed the shift toward a collaborative model (IHI, 2017a; NCSBN et al., 2006). As noted, there are some successful models of consensus building in some sectors of health care. These models, across disciplines, must be replicated more widely in health care if barriers to successful interprofessional collaboration are to be reduced. Exemplar 12.4 is an example of how APRNs from different specialties can work together to alter a hospital policy. They pooled the expertise in their particular specialty and their knowledge of the political issues that often surround hospital-based work. They knew that if they wanted to make this change, the key players in the decision-making process would have to buy into the idea. The usual pattern is not to change because past policy and procedures have been in place and there is substantial pressure not to change something that is viewed as working. The pull of the familiar was in place, yet it was not working for the mothers who wanted different options available to them. Exemplar 12.4 Collaboration in Quality Improvement: Improved Analgesia and Anesthesia Options During Labor Ms. Smith is a certified nurse-midwife (CNM) who provides fullscope midwifery services to women who choose this approach for pregnancy and delivery. The birthing center at which Ms. Smith attends the delivery by her patients has a policy that women must choose no analgesia during labor and delivery or they must have an epidural. Many of the women were not happy with having only two choices. Some women believed that they might need some help with the pain of delivery but did not want to be confined to labor in a bed by use of the traditional epidural anesthesia. Ms. Smith investigated this issue and found that the policy seemed to have been developed in the past by a committee that consisted of obstetrics and gynecology (OB-GYN) physicians and anesthesiologists. The policy was approved by the medical staff. No mothers, CNMs, or certified registered nurse anesthetists (CRNAs) were part of the policy making. There have been a number of advances in care since this policy was developed, and Ms. Smith wished to bring about a change to improve care to the mothers and their families. In this particular facility, only anesthesia providers (physician or CRNA) were credentialed to administer any analgesic or anesthetic agents, a practice touted as necessary for the quality of care for recipients of these agents. Ms. Smith did not believe that she would be able to alter this policy, nor did she really wish to do so. However, she wanted to provide an expanded set of options for her mothers. Although many of the mothers did not choose to receive any analgesia for labor or delivery, they wanted to have the option available prior to needing it. Ms. Smith consulted with a CRNA colleague who specialized in obstetric anesthesia. They met and discussed a number of options and decided that there were types of epidural approaches that could allow the mother to continue to walk while in labor and thereby improve the likelihood of a normal vaginal birth. Also, additional approaches were added to the list of available agents. One was a handheld device that delivered inhaled nitrous oxide when the mother thought she needed it. The services of a pediatric nurse practitioner were requested because the advanced practice registered nurses (APRNs) believed that the substantial literature on the topic indicated that newborns have better outcomes if the mother does not receive a standard epidural and that normal vaginal birth could be encouraged. This trio of APRNs crafted the new policy proposal; engaged support from the Chair of OB-GYN, Chair of Pediatrics, Chair of Anesthesiology, and nursing supervisor; and advanced the change in policy to the medical staff committee. After a great deal of argument, discussion, and negotiation, the policy was changed and approved by the hospital board. Now, women could choose from a wide range of approaches that best met their wishes and particular situations. This group of APRNs knew that there were some parts of the policy that would not change, including the administration of anesthetics by anesthesia providers only. Also, all the anesthesiologists and CRNAs who provided obstetric anesthesia were not equally adept at all the new approaches, so the CRNA provided in-service education for them. The nursing staff of the birthing center needed additional training and the CNM provided this education, along with the CRNA. Although the change in policy was created to accommodate the wishes of the patients in the midwifery practice, the outcome was that all women who delivered in the facility now had options that improved their satisfaction and quality of care. In addition, all the APRN caregivers believed that they had enhanced the labor experience of their maternity patients. These APRNs all knew that in their facility, policy approval was the purview of the medical staff. They would have to be included to make this change. Also, the hospital was governed by strong department chairs in medicine and they would also have to agree. These APRNs well understood that science, although critically important, was not sufficient to bring about this change. All the stakeholders had to be included. The APRNs knew which parts of the policy were open for negotiation and which were not, and crafted their proposal cleverly. This change did not happen quickly; several months were required to gain the support of all the key players. However, in the end, the women who used the birthing center were greatly advantaged by the collaborative efforts of all involved. Conclusion Many of the barriers to successful collaboration occur because of values, beliefs, and behaviors that have until recently gone unchallenged in society and in the organizations in which nurses practice. Radical change is needed if the conditions conducive to collaboration are to become the norm. Collaborative relationships not only are professionally satisfying but also improve access to care and patient outcomes. Although APRNs collaborate successfully with many individuals within and outside of nursing, they may find that one of their most important collaborative relationships—with physicians—may also be the most challenging. Despite the fact that there are many successful individual APRN-physician collaborative practices, including many with evidence demonstrating their beneficial effects on health care, tradition and stereotypes are often powerful negative influences on policymaking and in health care and professional organizations. To meet the demands for cost-effectiveness and quality, clinicians from all disciplines have been meeting together to discuss the care they provide and to define ways to deliver it to maximize quality and minimize duplication of effort. These interactions foster the trust and respect required for mature collaboration. They enable collaborators to recognize their interdependence and value the input of others, thus creating a synergy that improves the quality of clinical decision making. Systems citizenship starts with seeing the systems we have shaped and that in turn shape us (Friedman, 2005). Collaboration becomes a priority as global interconnectedness enters our everyday interactions in the complex health care arena in which APRNs practice. In today's health care environment, collaboration may flourish, regardless of the barriers identified in this chapter. Key Summary Points ■ There is a need for a better understanding of the organizational structures, communication processes, and interactive styles that enable clinicians to collaborate in ways that benefit clinical processes and outcomes. ■ APRNs can contribute to this understanding in several ways: ■ By documenting and analyzing their experiences with collaboration in published case studies; ■ By serving as preceptors for students and helping them develop the skills essential for collaboration; and ■ By working with researchers who are studying the characteristics and clinical implications of collaboration. ■ Effective collaboration must be at the heart of any redesign of the health care delivery system whether that redesign occurs in a unit, in a clinic, within and between organizations, or globally. References Agency for Healthcare Research and Quality. Defining the PCMH. [n.d.; Retrieved from] https://pcmh.ahrq.gov/page/defining-pcmh. Alberto J, Herth K. 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Nursing Outlook. 2012;59:243–251. CHAPTER 13 Ethical Decision Making Lucia Wocial “The very first requirement in a hospital is that it should do the sick no harm.” —Florence Nightingale CHAPTER CONTENTS Foundations of Ethical Practice, 310 Characteristics of Ethical Challenges in Nursing, 311 Communication Problems, 313 Interprofessional Conflict, 313 Multiple Commitments, 314 Ethical Issues Affecting APRNs, 314 Primary Care Issues, 314 Acute and Chronic Care Issues, 315 Societal Issues, 315 Access to Resources and Issues of Justice, 317 Legal Issues, 318 Ethical Decision-Making Competency of APRNs, 319 Elements of Core Competency Development, 319 Evaluation of the Ethical Decision-Making Competency, 335 Barriers to Ethical Practice and Potential Solutions, 337 Barriers Internal to the APRN, 337 Interprofessional Barriers, 337 Patient-Provider Barriers, 338 Organizational and Environmental Barriers, 339 Conclusion, 340 Key Summary Points, 342 The author would like to acknowledge Ann B. Hamric and Sarah A. Delgado for their work on previous editions of this chapter. Nurses in all areas of health care routinely encounter disturbing moral issues, yet the success with which these dilemmas are resolved varies significantly. Because nurses have a unique relationship with the patient and family, the moral position of nursing in the health care arena is distinct. As the complexity of issues intensifies, the role of the advanced practice registered nurse (APRN) becomes particularly important in the identification, deliberation, and resolution of complicated and difficult moral problems. Although all nurses are moral agents, APRNs are expected to be not just leaders in recognizing and resolving moral problems, but role models, creating ethical practice environments and promoting social justice in the larger health care system. They are expected to exercise their moral agency; that is, fulfill their obligation to act to do good work. It is a basic tenet of the central definition of advanced practice nursing (see Chapter 3) that skill in ethical decision making is one of the core competencies of all APRNs. In addition, the Doctor of Nursing Practice (DNP) essential competencies emphasize leadership in developing and evaluating strategies to manage ethical dilemmas in patient care and organizational arenas (American Association of Colleges of Nursing [AACN], 2006). This chapter explores the distinctive ethical decision-making competency of advanced practice nursing, the process of developing and evaluating this competency, and barriers to ethical practice that APRNs can expect to confront. Foundations of Ethical Practice Perhaps one of the biggest challenges for APRNs in attaining competence in ethical decision making is the path taken to become an APRN. Some individuals will pursue APRN education after years of clinical practice and others will begin practice as an APRN with no experience in nursing. As a profession, we expect nurses to demonstrate everyday ethical comportment, to integrate a strong moral competence into every aspect of nursing practice (Benner, Sutphen, Leonard, & Day, 2010). This requires at the very least cultivating one's moral sensitivity, which is an individual's capacity, acquired through experience, to sense the moral significance of a situation (Lützén, Dahlqvist, Eriksson, & Norberg, 2006). This necessitates a capacity to distinguish between feelings, facts, and values and reflect on these with the ability to articulate what is good, recognizing that defining what is good can be fraught with pitfalls if one has not engaged in rigorous self-reflection of personal values and potential biases (Feister, 2015). Evidence suggests that when people face ethical decisions, they engage in mental processes outside their conscious awareness (may rely on intuition) and their decisions may be affected by their emotional state (Guzak, 2015). Ethically challenging situations often evoke strong emotions. Guarding against emotional responses in ethically challenging situations requires APRNs to rigorously and continuously practice self-awareness, becoming exquisitely sensitive to their own hidden biases, which in turn helps them develop strong moral agency. The Code of Ethics for Nurses includes a provision calling attention to the duties nurses owe to themselves, including preservation of wholeness of character and integrity (ANA, 2015). This attention to the self enables nurses to hold themselves and others accountable even and especially in emotionally charged situations. One often overlooked element of ethical practice is a deep understanding of dignity and the role it plays in fostering positive relationships. While each of us desires to be treated with dignity, we have an innate talent for lashing out when we feel our dignity is violated. Our default is to attack, which contributes to a cycle of psychologic warfare against others, effectively destroying relationships and poisoning the environment (Hicks, 2003). When we learn to embrace the essential elements of dignity (Table 13.1), we can overcome our autopilot and promote healthy human relationships, which are essential for an ethical environment. Exemplar 13.1 is a brief but powerful example of how an APRN demonstrates how to honor dignity through everyday ethical comportment. TABLE 13.1 Adapted from Hicks, D. (2011). The dignity model. Retrieved from http://www.pyeglobal.org/wp-content/uploads/2013/09/Summary_of_Dignity_Model.pdf. Exemplar 13.1 Clinical Situation Demonstrating Everyday Ethical Comportment: Honoring Dignitya Lori is a clinical nurse specialist who is eager to promote evidencebased practice changes. Armed with the latest research demonstrating the effectiveness of simple interventions to reduce urinary catheter–related infections, she encounters Kathy, a busy direct care nurse. Following Hicks' (2003) essential elements of dignity (see Table 13.1), Lori approaches Kathy as a colleague, not one who has superior knowledge. Lori knows Kathy has not attended her in-service program outlining the new protocol and, rather than mention that, Lori acknowledges the heavy patient assignment Kathy is managing and complements her on her organization. When Kathy mentions that there is an order for a routine culture of the urinary catheter, Lori takes the opportunity to explain key points from the new protocol. Lori cheerfully offers to contact the physician, giving him the benefit of the doubt that he did not realize there was a new nurse-led protocol to guide appropriate removal of urinary catheters and check cultures only when a patient is symptomatic. Despite Lori's best efforts, Kathy feels that Lori has not been responsive to the workload she faces and lashes out at Lori, suggesting she is pushing this new protocol simply because it will save money. Lori does not respond to Kathy's heated comments. She instead helps Kathy focus on the primary goal, reducing the risk of infection for the patient. Lori offers to help Kathy remove the catheter, and makes several suggestions to assure the patient has assistance to void, including returning in an hour to help Kathy monitor the patient to make sure he has assistance to void. a Thanks to Lori Alesia, MN, CNS, RN, for her assistance with this exemplar. Characteristics of Ethical Challenges in Nursing In this chapter, the terms ethics and morality or morals are used interchangeably (see Beauchamp & Childress, 2012, for a discussion of the distinctions between these terms). A problem becomes an ethical or moral problem when issues of core values or fundamental obligations are present. An ethical or moral dilemma occurs when obligations require or appear to require that a person adopt two (or more) alternative actions, but the person cannot carry out all the required alternatives. The agent experiences tension because of the moral obligations resulting from the dilemma of differing and opposing demands (Beauchamp & Childress, 2012; Doherty & Purtilo, 2016). In some moral dilemmas, the agent must choose between equally unacceptable alternatives; that is, both may have elements that are morally unsatisfactory. For example, based on her evaluation, a family nurse practitioner (FNP) may suspect that a patient is a victim of domestic violence, although the patient denies it. The FNP is faced with two options that are both ethically troubling: connect the patient with existing social services, possibly straining the family and jeopardizing the FNP-patient relationship, or avoid intervention and potentially allow the violence to continue. As described by Silva and Ludwick (2002), honoring the FNP's desire to prevent harm (the principle of nonmaleficence) justifies reporting the suspicion, whereas respect for the patient's autonomy justifies the opposite course of action. Jameton (1984, 1993) has distinguished two additional types of moral problems from the classic moral dilemma, which he termed moral uncertainty and moral distress. In situations of moral uncertainty, the nurse experiences unease and questions the right course of action. When nurses experience moral distress, they believe that they know the ethically appropriate action but feel constrained from carrying out that action because of institutional obstacles (e.g., lack of time or supervisory support, physician power, institutional policies, legal constraints). There is growing recognition that moral distress is a complex construct with considerable debate over an exact definition (Fourie, 2015; Hamric, 2012; Musto et al., 2015). Noting that nurses and others often take varied actions in response to moral distress, Varcoe, Pauly, Webster, and Storch (2012) have proposed a revision to Jameton's definition: [M]oral distress is the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment. (p. 60) The phenomenon of moral distress has received increasing national and international attention in nursing and medical literature. There is growing recognition that failing to address moral distress may have negative consequences for clinicians and patients. Moral distress occurs when conscientious persons are practicing in challenging contexts and is not due to moral weakness of the person experiencing it (Garros, Austin, & Carnevale, 2015; Halpern, 2011). Studies have reported that moral distress is significantly related to unit-level ethical climate and to health care professionals' decisions to leave clinical practice (Corley, Minick, Elswick, & Jacobs, 2005; Epstein & Hamric, 2009; Hamric, Borchers, & Epstein, 2012; Hamric, Davis, & Childress, 2006; Lamiani, Borghi, & Argentero, 2015; Pauly, Varcoe, Storch, & Newton, 2009; Schluter, Winch, Holzhauser, & Henderson, 2008; Varcoe et al., 2012; Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). APRNs work to decrease the incidence of moral uncertainty and moral distress for themselves and their colleagues through honest self-reflection, education, empowerment, and problem solving. Although the scope and nature of moral problems experienced by nurses, and more specifically APRNs, reflect the varied clinical settings in which they practice, three general themes emerge when ethical issues in nursing practice are examined. These are problems with communication, the presence of interprofessional conflict, and nurses' difficulties with managing multiple commitments and obligations. Communication Problems The first theme encountered in many ethical dilemmas is the erosion of open and honest communication. The erosion begins when clinicians fail to speak up in crucial situations. Research suggests that even when patient safety is at risk, fewer than 2 in 10 clinicians will speak up (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005; Maxfield, Grenny, Lavandero, & Groah, 2010). With medical error now listed as one of the leading causes of death in the United States (Makary & Daniel, 2016), it is essential that we focus on stopping the silent erosion of communication. APRNs must be willing and able not only to speak up in high stakes situations but to coach nurses in how to break the silence and create an atmosphere in which open communication is the rule rather than the exception. Clear communication is an essential prerequisite for informed and responsible decision making. Some ethical disputes reflect inadequate communication rather than a difference in values (Hamric & Blackhall, 2007; Ulrich, 2012). The APRN's communication skills are applied in several arenas. Within the health care team, discussions are most effective when members are accountable for presenting information in a precise and succinct manner. In patient encounters, disagreements between the patient and a family member or within the family can be rooted in faulty communication, which then leads to ethical conflict. The skill of listening is just as crucial in effective communication as having proficient verbal skills. Listening involves recognizing and appreciating various perspectives and showing respect to individuals with differing ideas. To listen well is to allow others the necessary time to form and present their thoughts and ideas. Understanding the language used in ethical deliberations (e.g., terms such as beneficence, autonomy, and utilitarian justice) helps the APRN frame the concern in rational terms. This can help those involved to see the components of the ethical problem rather than be mired in their own emotional responses. When ethical dilemmas arise, effective communication is the first key to negotiating and facilitating a resolution. For example, Jameson (2003) found that when certified registered nurse anesthetists (CRNAs) and anesthesiologists focused on the common goal of patient care (shared values) rather than on the conflicting opinions about supervision and autonomous practice, they were able to transcend role-based conflict and promote effective communication. Interprofessional Conflict The second theme encountered is that most ethical dilemmas that occur in the health care setting are multidisciplinary in nature. Issues such as refusal of treatment, end-of-life decision making, cost containment, and confidentiality all have interprofessional elements interwoven in the dilemmas, so an interprofessional approach is necessary for successful resolution of the issue. Health care professionals bring varied viewpoints and perspectives into discussions of ethical issues (Hamric & Blackhall, 2007; Piers et al., 2011; Shannon, Mitchell, & Cain, 2002). These differing positions can lead to creative and collaborative decision making or to a breakdown in communication and lack of problem solving. Thus an interprofessional theme is necessary in the presentation and resolution of ethical problems. For example, a clinical nurse specialist (CNS) is facilitating a discharge plan for an older woman who is terminally ill with heart failure. The plan of care, agreed on by the interprofessional team, patient, and family, is to continue oral medications but discontinue intravenous inotropic support and all other aggressive measures. Just prior to discharge, the social worker laments to the CNS that medical coverage for the patient's care in the skilled nursing facility will be covered by the insurer only if the patient has an intravenous line in place. The patient's daughter wishes to take her mother home and provide care. The attending cardiologist determines that the patient can be discharged to her daughter's home because she no longer requires skilled care; however, the bedside nurse is concerned that the patient's need for physical assistance will overwhelm her daughter and believes that the patient is better off returning to the skilled nursing facility. The CNS engages the patient in a careful conversation about her condition and her preferences. Although each team member shares responsibility to ensure that the plan of care is consistent with the patient's wishes and minimizes the cost burden to the patient, they differ in perspective and approach for how to achieve these goals. Such legitimate but differing perspectives from various team members can lead to ethical conflict. Multiple Commitments The third theme that frequently arises when ethical issues in nursing practice are examined is the issue of balancing commitments to multiple parties. Nurses have numerous and, at times, competing fidelity obligations to various stakeholders in the health care and legal systems (Chambliss, 1996; Hamric, 2001). Fidelity is an ethical concept that requires persons to be faithful to their commitments and promises. For the APRN, these obligations start with the patient and family but also include physicians and other colleagues, the institution or employer, the larger profession, and oneself. Ethical deliberation involves analyzing and dealing with the differing and opposing demands that occur as a result of these commitments. An APRN may face a dilemma if encouraged by a specialist consultant to pursue a costly intervention on behalf of a patient, whereas the APRNS's hiring organization has established cost containment as a key objective and does not support use of this intervention (Donagrandi & Eddy, 2000). In this and other situations, APRNs are faced with an ethical dilemma created by multiple commitments and the need to balance obligations to all parties. Another significant threat to ethical practice is the failure of APRNs to practice self-care. As noted in the Code of Ethics for Nurses (American Nurses Association [ANA], 2015), nurses owe the same duty to themselves that they do to their patients. For example, an APRN may receive a referral to see a patient late in the day. She will feel compelled to stay late and meet the patient's needs, even if she has already worked well beyond a “normal” day. As a one-time event, this is laudable. When it becomes a pattern, particularly when the APRN is sacrificing personal time or family time, she puts herself at risk for long-term health consequences (Fox, Dwyer, & Ganster, 1993). Something as commonplace as interrupted sleep or lack of sleep contributes to a negative emotional state (Tempesta et al., 2010), which in turn may deplete self-control and lead to unethical behavior (Barnes, Schaubroeck, Huth, & Ghumman, 2011; Gino, Schweitzer, Mead, & Ariely, 2011). The general themes of communication, interprofessional conflict, and balancing multiple commitments are prevalent in most ethical dilemmas. Specific ethical issues may be unique to the specialty area and clinical setting in which the APRN practices. Ethical Issues Affecting APRNs Primary Care Issues Situations in which personal values contradict professional responsibilities often confront nurse practitioners (NPs) in a primary care setting. Issues such as abortion, teen pregnancy, patient nonadherence to treatment, childhood immunizations, regulations and laws, and financial constraints that interfere with care were cited in one older study as frequently encountered ethical issues (Turner, Marquis, & Burman, 1996). Ethical problems related to insurance reimbursement, such as when implementation of a desired plan of care is delayed by the insurance authorization process or restrictive prescription plans, are an issue for APRNs. NPs practicing within a managed care environment often feel the necessity to balance the needs of patients against the organization's interests (Ulrich, Soeken, & Miller, 2003). The problem of inadequate reimbursement can also arise when there is a lack of transparency regarding the specifics of services covered by an insurance plan. For example, a patient who has undergone diagnostic testing during an inpatient stay may later be informed that the test is not covered by insurance because it was done on the day of discharge. Had the patient and NP known of this policy, the testing could have been scheduled on an outpatient basis with prior authorization from the insurance company and thus have been a covered expense. Viens (1994) found that primary care NPs interpret their moral responsibilities as balancing obligations to the patient, family, colleagues, employer, and society. More recently, Laabs (2005) has found that the three issues most often noted by NPs as causing moral dilemmas are (1) being required to follow policies and procedures that infringe on personal values, (2) wanting to bend the rules to ensure appropriate patient care, and (3) dealing with patients who have refused appropriate care. Issues leading to moral distress in NPs included pressure to see an excessive number of patients, clinical decisions being made by others, and a lack of power to effect change (Laabs, 2005). Increasing expectations to care for more patients in less time are routine in all types of health care settings as pressures to contain costs escalate. APRNs in rural or ambulatory care settings often have fewer resources than their colleagues working in or near academic centers in which ethics committees, ethics consultants, and educational opportunities are more accessible. Issues of quality of life and symptom management traverse primary and acute health care settings. Pain relief and symptom management can be problematic for nurses and physicians (Oberle & Hughes, 2001). APRNs must confront the various and sometimes conflicting goals of the patient, family, and other health care providers regarding the plans for treatment, symptom management, and quality of life. The APRN is often the individual who coordinates the plan of care and thus is faced with clinical and ethical concerns when participants' goals are not consistent or appropriate. Acute and Chronic Care Issues In the acute care setting, APRNs struggle with dilemmas involving pain management, end-of-life decision making, advance directives, assisted suicide, and medical errors (Shannon, Foglia, Hardy, & Gallagher, 2009). Rajput and Bekes (2002) identified ethical issues faced by hospital-based physicians, including obtaining informed consent, establishing a patient's competence to make decisions, maintaining confidentiality, and transmitting health information electronically. APRNs in acute care settings may experience similar ethical dilemmas. Recent studies of moral distress have revealed that feeling pressured to continue aggressive treatments that respondents thought were not in the patients' best interest or in situations in which the patient was dying, working with physicians or nurses who were not fully competent, giving false hope to patients and families, poor team communication, and lack of provider continuity were all issues that engendered moral distress (Hamric & Blackhall, 2007; Hamric et al., 2012). Emergency department NPs experience moral distress with poor patient care results related to inadequate staff communication and working with incompetent coworkers in their practice (Trautmann, Epstein, Rovnyak, & Snyder, 2015). APRNs bring a distinct perspective to collaborative decision making and often find themselves bridging communication between the medical team and patient or family. For example, the neonatal nurse practitioner (NNP) is responsible for the day-to-day medical management of the critically ill neonate and may be the first provider to respond in emergency situations (Juretschke, 2001). The NNP establishes a trusting relationship with the family and becomes aware of the values, beliefs, and attitudes that shape the family's decisions. Thus the NNP has insight into the perspectives of the health care team and family. This “in-the-middle” position, however, can be accompanied by moral distress (Hamric, 2001), particularly when the team's treatment decision carried out by the NNP is not congruent with the NNP's professional judgment or values. Botwinski (2010) conducted a needs assessment of NNPs and found that most had not received formal ethics content in their education and desired more education on the management of end-of-life situations, such as delivery room resuscitation of a child on the edge of viability. Knowing the best interests of the infant and balancing those obligations to the infant with the emotional, cognitive, financial, and moral concerns that face the family struggling with a critically ill neonate is a complex undertaking. Care must be guided by an NNP and health care team who understand the ethical principles and decision making related to issues confronted in neonatal intensive care unit practice. Societal Issues Ongoing cost containment pressures in the health care sector have significantly changed the traditional practice of delivering health care. Goals of reduced expenditures and increased efficiency, although important, may compete with enhanced quality of life for patients and improved treatment and care, creating tension between providers and administrators, particularly as reimbursement changes from a procedure-based to a quality/value-based system. Studies suggest that changes in payment systems can lead to ethical challenges for providers. Ulrich and associates (2006) surveyed NPs and physician assistants to identify their ethical concerns in relation to cost containment efforts, including managed care. They found that 72% of respondents reported ethical concerns related to limited access to appropriate care and more than 50% reported concerns related to the quality of care. An earlier study of 254 NPs revealed that 80% of the sample perceived that to help patients, it was sometimes necessary to bend practice or institutional policies to provide appropriate care (Ulrich et al., 2003). Most respondents in this study reported being moderately to extremely ethically concerned with cost containment; more than 50% said that they were concerned that business decisions took priority over patient welfare and more than 75% stated that their primary obligation was shifting from the patient to the insurance plan. Although many hoped the passage of the Patient Protection and Affordable Care Act (ACA, 2010) would help with these concerns to some extent, the ethical tensions that underlie cost containment pressures and the business model orientation of health care delivery no doubt will continue. Changes in government leadership bring shifts in health care policy, and the 2016 election is a prime example. Ongoing attempts to repeal and replace the ACA have highlighted the complexity of the healthcare system and vividly underscore the ongoing debate about what constitutes “fair” distribution of resources, different conceptions of what is good, and a predisposition to seek power and advantage (Obama, 2017; Sorrell, 2012). Even as lawmakers debate how to address healthcare delivery, real life challenges such as the opiate epidemic will stress the system and pose more ethical challenges for advanced practice nurses ((Friedmann, Andrews & Humphreys, 2017). A survey of primary care providers—physicians, NPs, and physician assistants—indicates that overall, providers are more negative about the increased reliance on quality metrics and financial penalties to promote high performance (Commonwealth Fund and Henry J. Kaiser Family Foundation, 2015). It may be too soon to know for sure; however, history suggests ethical challenges will continue as the system of health care delivery evolves. While a number of myths surround the impact of patient satisfaction scores on reimbursement, the data suggest that patients are good discriminators of the care they receive. Ultimately, it is about communication and relationships, not simply acquiescing to what a patient says he or she wants (Siegrist, 2013). An example of how cost containment goals can create conflict is a situation in which an NP wishes to order a computed tomography scan to evaluate a patient complaining of abdominal pain. The NP knows that the patient has a history of diverticulosis resulting in abscess formation, and the current presentation with fever and abdominal tenderness justifies this testing; however, the insurance approval process takes a minimum of 24 hours. By sending the patient to the emergency room, the test can be done more quickly, but the patient will also face a long wait and a high co-pay if she does not require subsequent hospital admission. Limiting access to computed tomography scans is based on containing costs and avoiding unnecessary testing, which are two laudable goals. In this situation, the lengthy approval process means that the NP must make decisions about the treatment plan without important information. The pressure to alleviate the patient's suffering in a timely manner may tempt the NP to advise the patient to go to the emergency room, which may result in a greater financial burden on the patient and may ultimately prove more expensive to the system. The availability of modern technology forces difficult choices, especially challenging providers to redefine “timely,” urgent, and emergent, and may cause providers to feel as though they are choosing between what is best for patients and what is best for organizations. Technologic advances, such as the rapidly expanding field of genetics, are also challenging APRNs (Caulfield, 2012; Harris, Winship, & Spriggs, 2005; Horner, 2004; Pullman & Hodgkinson, 2006). As Hopkinson and Mackay (2002) have noted, although the potential impact of mapping the human genome is immense, the challenge of how to translate genetic data rapidly into improvements in the prevention, diagnosis, and treatment of disease remains. To counsel patients effectively on the risks and benefits of genetic testing, APRNs need to stay current in this rapidly changing field. A helpful resource for this and other issues is the text by Steinbock, Arras, and London (2012) and a more recent article by Seibert (2014). As one example, genetic testing poses a unique challenge to the informed consent process. Direct-to-consumer marketing, with phrases such as “Your DNA has an incredible story!” by companies that provide genetic testing, projects an image of a cutting-edge, risk-free opportunity (https://www.23andme.com). Patients may feel pressured by family members to undergo or refuse testing, and they may require intensive counseling to understand the complex implications of such testing (Erlen, 2006). APRNs may be involved in posttest counseling, helping patients navigate such thorny issues as disclosure of test results to family members or potential future family members and what to do if the information makes its way to an employer or insurance company. Because genetic information is crucially linked to the concepts of privacy and confidentiality, and the availability of this information is increasing, it is inevitable that APRNs will encounter legal issues and ethical dilemmas related to the use of genetic data. The cost of genomic testing may effectively put this technology out of reach for disadvantaged populations. It will be important for the health care system to create a model that will ensure the sustainability of funding for genomic-guided interventions, their adoption and coverage by health insurance, and prioritization of genomic medicine research, development, and innovation (Fragoulakis, Mitropoulou, van Schaik, Maniadakis, & Patrinos, 2016). APRNs may engage in research as principal investigators, coinvestigators, or data collectors for clinical studies and trials. In addition, leading quality improvement initiatives is a key expectation of the DNP-prepared APRN (AACN, 2006). Ethical issues abound in clinical research, including recruiting and retaining patients in studies, protecting vulnerable populations from undue risk, and ensuring informed consent, fair access to research, and study subjects' privacy. As APRNs move into quality improvement and research initiatives, they may experience the conflict between the clinician role, in which the focus is on the best interests of an individual patient, and that of the researcher, in which the focus is on ensuring the integrity of the study (Edwards & Chalmers, 2002). Access to Resources and Issues of Justice Issues of access to and distribution of resources create powerful dilemmas for APRNs, many of whom care for underserved populations. Issues of social justice and equitable access to resources present formidable challenges in clinical practice. Trotochard (2006) noted that a growing number of uninsured individuals lack access to routine health care; they experience worse outcomes from acute and chronic diseases and face higher mortality rates than those with insurance. McWilliams, Meara, Zaslavsky, and Ayanian (2007) found that previously uninsured Medicare beneficiaries require significantly more hospitalizations and office visits when compared with those with similar health problems who, prior to Medicare eligibility, had private insurance. The ACA has improved access to quality care and decreased the incidence of these circumstances. Regardless of patients' insurance status, the costs of health care will continue to present ethical dilemmas for providers. The shift in payment structure to a value-based system adds to the complexity of health care reform. A report of projects funded by the Robert Wood Johnson Foundation concluded that achieving the objectives of reduced cost and improved quality will require a trusted, widely respected “honest broker” that can convene and maintain the ongoing commitment of health plans, providers, and purchasers (Conrad, Grembowski, Hernandez, Lau, & Marcus-Smith, 2014). The allocation of scarce health care resources also creates ethical conflicts for providers; regardless of payment mechanisms, there are insufficient resources to meet all societal needs (Bodenheimer & Grumbach, 2012; Trotochard, 2006). Scarcity of resources is more severe in developing areas of the world, and justice issues of fair and equitable distribution of health care services present serious ethical dilemmas for nurses in these regions (Harrowing & Mill, 2010). A further international issue is the “brain drain” of nurses and other health professionals who leave underdeveloped countries to take jobs in developed countries (Chaguturu & Vallabhaneni, 2007; Dwyer, 2007). Allocation issues have been described in the area of organ transplantation, but dilemmas related to scarce resources also arise in regard to daily decision making, for example, with a CNS guiding the assignment of patients in a staffing shortage or an FNP finding that a specialty consultation for a patient is not available for several months. Whether in community or acute care settings, APRNs must, on a daily basis, balance their obligation to provide holistic, evidence-based care with the necessity to contain costs and the reality that some patients will not receive needed health care. As Bodenheimer and Grumbach (2012) have noted, “Perhaps no tension within the U.S. health care system is as far from reaching a satisfactory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services” (p. 215). One of the value-added components that APRNs bring to any practice setting is creativity and a wide range of patient management strategies, which are crucial in caring for large numbers of uninsured and underinsured persons. It is not uncommon for an APRN to encounter a patient who has been forced to stop taking certain medications for financial reasons. Although many practitioners prescribe generic forms of medications, if available, some patients still have to pay an exorbitant price for their medications. For example, an acute care nurse practitioner (ACNP) managing an underinsured patient with chronic lung disease and heart failure discovers that the patient is unable to pay for all the medications prescribed and has elected to forego the diuretic and an angiotensin-converting enzyme inhibitor. Because the ACNP knows that angiotensin-converting enzyme inhibitors are associated with reduced morbidity and mortality rates, and that diuretics control symptoms and prevent rehospitalization, these changes are discouraged. Instead, the ACNP helps the patient make more suitable choices when altering medications, such as dosing some medications on an every-other-day basis. The ACNP has helped the patient cope with the situation but must face the morally unsettling fact that this plan of care is medically inferior. Finally, as APRNs broaden their perspectives to encompass population health and increased policy activities, both essential competencies of the DNP-prepared APRN (AACN, 2006), they will experience the tension between caring for the individual patient and the larger population (Emanuel, 2002). Caregivers are increasingly being asked to incorporate population-based cost considerations into individualized clinical decision making (Bodenheimer & Grumbach, 2012). Population-based considerations present a challenge to APRNs, who have been educated to privilege the individual clinical decision. Legal Issues Over the last 30 years, the complexity of ethical issues in the health care environment and the inability to reach agreement among parties has resulted in participants turning to the legal system for resolution. A body of legal precedent has emerged, reflecting changes in society's moral consensus. Ideally, moral rights are upheld or protected by the law. For example, the culturally and linguistically appropriate services standards mandate that health care institutions receiving federal funds provide services that are accessible to patients regardless of their cultural background (US Department of Health and Human Services, Office of Minority Health, 2001). These standards provide a legislative voice for the ethical obligation to respect all persons, regardless of their cultural background and primary language. In a different voice, the ACA (2010) has mandated that persons who can afford health insurance purchase it or pay a penalty. According to this law, societal beneficence, in the form of limiting high expenditures on the care of uninsured persons, is preferred over individual autonomy (Trautman, 2011). APRNs must use caution and not conflate legal perspectives with ethical decision making. In many cases, there is no relevant law to guide decision making. Thoughtful deliberation of the ethical issues rather than searching for a legal answer to avoid litigation offers the best hope of resolution. In addition, looking to the judicial system for guidance in ethical decision making is troubling because the judicial aim is to interpret the law, not to satisfy the ethical concerns of all parties involved. In addition, clinical understanding may be absent from the judicial perspective. Involvement of the media may further confuse the situation, as was evident in the Schiavo case (Gostin, 2005). At age 26, Terri Schiavo was in a persistent vegetative state following cardiac arrest and severe anoxic brain damage. Ms. Schiavo had no advance directive, and her husband was appointed her guardian. Her parents did not contest this until a lawsuit resulted in a financial settlement with money put in trust to provide care for her. Mr. Schiavo wished to remove his wife's feeding tube and her parents wished to keep her alive. The legal guidelines in that case were clear; the Florida court system repeatedly upheld the right of Ms. Schiavo's spouse to refuse nutrition and hydration on her behalf. However, advocacy groups, politicians, and Ms. Schiavo's parents used the media to offer a variety of interpretations of the case and wielded political power to prevent removal of the feeding tube and to have it replaced twice after it was removed. Clearly, the legal perspective did not satisfy the moral concerns of all involved. Unfortunately, much of the publicity about the case focused on the emotional experience of the parents fearing the loss of their daughter and not on the medical facts of the case or careful consideration of the ethical elements. Sometimes, the law not only falls short of resolving ethical concerns but contributes to the creation of new dilemmas. Changes in the Medicare hospice benefit under the ACA (2010) offer a clear example. Designed to prevent hospice agencies from enrolling and reenrolling patients who do not meet criteria, the new regulations require a faceto-face assessment by a health care provider to recertify hospice eligibility at set intervals after the initial enrollment (Kennedy, 2012). Often, patients with dementia or another slowly progressive disease who enroll in hospice experience an initial period of stability, likely because they have improved symptom management and access to comprehensive services. If this stability extends to the next certification period, the patient may face disenrollment. For the practitioner conducting the assessment, this creates the ethical dilemma of wanting to be truthful regarding the patient's status and at the same time avoiding removing a service that is benefiting the patient and family. Ethical Decision-Making Competency of APRNs There are a number of reasons why ethical decision making is a core competency of advanced practice nursing. As noted, clinical practice gives rise to numerous ethical concerns and APRNs must be able to address these concerns. Also, ethical involvement follows and evolves from clinical expertise (Benner, Tanner, & Chesla, 2009). Another reason why ethical decision making is a core competency can be seen in the expanded collaborative skills that APRNs develop (see Chapter 12). APRNs practice in a variety of settings and positions but, in most cases, the APRN is part of an interprofessional team of caregivers. The team may be loosely defined and structured, as in a rural setting, or more definitive, as in the acute care setting. The recent reemergence of an interprofessional care model is changing practice for all providers (Interprofessional Education Collaborative [IPEC], 2016). Regardless of the structure, APRNs need the knowledge and skills to avoid power struggles, broker and lead interprofessional communication, and facilitate consensus among team members in ethically difficult situations. Elements of Core Competency Development The core competency of ethical decision making for APRNs can be organized into four elements (Fig. 13.1). Each element is enhanced by the acquisition of the knowledge and skills embedded in other areas. The competency of ethical decision making is understood as an evolutionary process in an APRN's development. APRNs should be exposed to all elements in graduate school; however, particular attention should be paid to knowledge acquisition and developing moral sensitivity. The other elements of the ethical decision-making competency evolve as APRNs mature in their roles and develop clinical expertise, becoming comfortable in the practice setting. Creating an ethical work environment and promoting social justice represent leadership behavior and the full enactment of the ethical decision-making competency. Although this is an expectation of the practice doctorate, all APRNs should develop their ethical knowledge and skills to include all four elements of this competency. The essential components of each element are described in Table 13.2 (Hamric & Delgado, 2014). FIG 13.1 Developing APRN ethical competency. TABLE 13.2 Modified from Hamric, A. B., and Delgado, S. (2014). Ethical decision making. In Advanced practice nursing: An integrative approach (5th ed., p. 334). St. Louis, MO: Elsevier. Element 1: Knowledge Development The first element in the ethical decision-making competency is developing core knowledge and terminology in ethical theories and principles and the ethical issues common to specific patient populations or clinical settings. This dual knowledge enables the APRN student to integrate philosophical concepts with contemporary clinical issues. The emphasis in this initial stage is on learning the language of ethical discourse and achieving cognitive mastery. The APRN learns the theories, principles, codes, paradigm cases, and relevant laws that influence ethical decision making. With this knowledge, the APRN begins to compare current practices in the clinical setting with the ethical standards described in the literature. Mastering the components of this element is the beginning of the APRN's personal journey toward developing a distinct and individualized ethical framework. Initially the APRN must work to develop sensitivity to the moral dimensions of clinical practice (Weaver, 2007). A helpful initial step in building moral sensitivity involves exploring one's values, intentionally clarifying the personal and professional values that inform one's practice (Feister, 2015; Fry & Johnstone, 2008). Engaging in this work uncovers personal values that may have been internalized and not openly acknowledged and is particularly important in today's multicultural world. Another key aspect of this element is developing the ability to distinguish a true ethical dilemma from a situation of moral distress or other clinically problematic situation. This requires a general understanding of ethical theories, principles, and standards that help the APRNs define and discern the essential elements of an ethical dilemma. Novice APRNs should be able to recognize a moral problem and seek clarification and illumination of the concern. Once an APRN can identify ethical issues and name the concerns about which others are uneasy, the APRN will gain self-confidence and begin to earn credibility with others. If the issue remains a moral concern after clarification, the APRN should pursue resolution, seeking additional help if needed. Although some beginning graduate students will have had significant exposure to ethical issues in their undergraduate programs, most have not. A 2008 US survey of nurses and social workers found that only 51% of the nurse respondents had formal ethics education in their undergraduate or graduate education; 23% had no ethics training at all (Grady et al., 2008). APRN students with no ethics education or clinical experience will be at a disadvantage in developing this competency because graduate education builds on the ethical foundation of professional practice. The current master's essentials (AACN, 2011) do not address ethics education directly but include competencies in the use of ethical theories and principles. The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) contains explicit ethical content in five of the eight major categories (Box 13.1). Even categories that do not explicitly list necessary ethical content imply it in referring to issues such as improving access to health care, addressing gaps in care, and using conceptual and analytic skills to address links between practice and organizational and policy issues. Box 13.1 Ethical Competencies in the DNP Essentialsa • Integrate nursing science with knowledge from ethics and biophysical, psychosocial, analytic, and organizational sciences as the basis for the highest level of nursing practice. (I) • Develop and/or evaluate effective strategies for managing the ethical dilemmas inherent in patient care, the health care organization, and research. (II) • Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable [emphasis added], and patient-centered care. (III) • Provide leadership in the evaluation and resolution of ethical and legal issues within health care systems relating to the use of information, information technology, communication networks, and patient care technology. (IV) • Advocate for social justice, equity, and ethical policies within all health care arenas. (V) a Essential number in parentheses. From American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author. Exposure to ethical theories, principles, and concepts is not enough. Processes that accommodate and value the unique nature of each ethical problem, incorporating personal values and ethical theories, are gaining influence (Cooper, 2012). Knowledge development must extend beyond classroom discussions to include discussion of ethical dimensions of clinical practicum experiences. In one study, Laabs (2005) noted that 67% of NP respondents claimed that they never or rarely encountered ethical issues. Some respondents showed confusion regarding the language of ethics and related principles. In a later study, Laabs (2012) found that APRN graduates, most of whom had had an ethics course in their graduate curriculum, indicated a fairly high level of confidence in their ability to manage ethical problems, but their overall ethics knowledge was low. These studies provide compelling commentary on the need for ethics knowledge development in graduate curricula. The core knowledge of ethical theories should be supplemented with an understanding of issues central to the patient populations with whom the APRN works. As APRNs assume positions in specific clinical areas or with particular patient populations, it is incumbent upon them to gain an understanding of the applicable laws, standards, and regulations in their specialty, as well as relevant paradigm cases. This information may be garnered from current literature in the field, continuing education programs, or discussions with colleagues. Information on legal and policy guidelines should be offered during graduate practicum experiences in the area of clinical concentration. Knowledge development is an ongoing process. APRNs will gain core knowledge in graduate education but, as societal issues change and new technologies emerge, new dilemmas and ethical problems arise. The ability to be a leader in creating ethical environments involves a commitment to lifelong learning about ethical issues, of which professional education is just the beginning. At least one study suggests it is continuing education in ethics beyond basic training that can have the largest impact on moral action (Grady et al., 2008). Developing an Educational Foundation Because the APRN will apply theories, principles, rules, and moral concepts in actual encounters with patients, it is imperative that consideration of the context in specific situations be strengthened. Simulation has been shown to be an effective environment for students to learn and practice skills necessary to navigate complex environments involving ethical conflict (Buxton, Phillippi, & Collins, 2015). Howard and Steinberg (2002) maintained that graduate curricula need to go beyond traditional ethical issues to encompass building trust in the APRN-patient relationship, professionalism and patient advocacy, resource allocation decisions, individual versus population-based responsibilities, and managing tensions between business ethics and professional ethics. As technology changes and new dilemmas confront practitioners, the APRN must be prepared to anticipate conditions that erode an ethical environment. Knowledge and skills in all phases of this competency depend on the application of current ethical knowledge in the clinical setting; ethical reasoning and clinical judgment share a common process and each serves to teach and inform the other (Dreyfus, Dreyfus, & Benner, 2009). Therefore the importance of clinical practice cannot be overemphasized. Overview of Ethical Approaches Principle-Based. Although ethical decision making in health care is extensively discussed in the bioethics literature, two dominant models are most often applied in the clinical setting. The first model of decision making is a principle-based model (Box 13.2), in which ethical decision making is guided by principles and rules (Beauchamp & Childress, 2012). In cases of conflict, the principles or rules in contention are balanced and interpreted with the contextual elements of the situation. However, the final decision and moral justification for actions are based on principles. In this way, the principles are binding and tolerant of the particularities of specific cases (Beauchamp & Childress, 2012). The principles of respect for persons, autonomy, beneficence, nonmaleficence, and justice are commonly applied in the analysis of ethical issues in nursing. The ANA Code of Ethics for Nurses (2015) has endorsed the principle of respect for persons and underscores the profession's commitment to serving individuals, families, and groups or communities. The emphasis on respect for persons throughout the code implies that it is not only a philosophical value of nursing but also a binding principle within the profession. Box 13.2 Principles and Rules Important to Professional Nursing Practice • Principle of respect for autonomy: The duty to respect others' personal liberty and individual values, beliefs, and choices • Principle of nonmaleficence: The duty not to inflict harm or evil • Principle of beneficence: The duty to do good and prevent or remove harm • Principle of formal justice: The duty to treat equals equally and treat those who are unequal according to their needs • Rule of veracity: The duty to tell the truth and not to deceive others • Rule of fidelity: The duty to honor commitments • Rule of confidentiality: The duty not to disclose information shared in an intimate and trusted manner • Rule of privacy: The duty to respect limited access to a person Adapted from Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press. Although ethical principles and rules are the cornerstone of most ethical decisions, the principle-based approach has been criticized as being too formalistic for many clinicians and lacking in moral substance (Gert, Culver, & Clouser, 2006). Other critics have argued that a principle-based approach conceals the particular person and relationships and reduces the resolution of a clinical case simply to balancing principles (Rushton & Penticuff, 2007). Because all the principles are considered of equal moral weight, this approach has been seen as inadequate to provide guidance for moral action (Gert et al., 2006; Strong, 2007). Another significant challenge to the principled approach is a shallow understanding of autonomy. Honoring a person's autonomy does not mean that that person should get whatever they want. Respect for persons (the broader understanding of autonomy) requires a more nuanced understanding of how to balance what a person may want with the responsibility to avoid harm and promote a person's well-being. This is especially important when, for example, APRNs face pressure from patients to prescribe medication they do not need or (worse) may cause them harm. In spite of these critiques, bioethical principles remain the most common ethical language used in clinical practice settings. Casuistry. The second common approach to ethical decision making is the casuistic model (Box 13.3), in which current cases are compared with precedent-setting cases (Beauchamp & Childress, 2012; Jonsen & Toulmin, 1988; Toulmin, 1994). The strength of this approach is that a dilemma is examined in a context-specific manner and then compared with an analogous earlier case. The fundamental philosophical assumption of this model is that ethics emerges from human moral experiences. Casuists approach dilemmas from an inductive position and work from the specific case to generalizations, rather than from generalizations to specific cases (Beauchamp & Childress, 2012). Box 13.3 Alternative Ethical Approaches Casuistry • Direct analysis of particular cases • Uses previous paradigm cases to infer ethical action in a curren