July, 2022

While this first class in my journey to becoming a better nurse kicked my butt, and while I tried my best to drop out during week 6, I rocked. 

My final grade: 96%

😀

MSN560: Transitions in Practice: The Role of the Advanced Practice Nurse

Course Description: This course focuses on the role and accountabilities of advanced practice nurses. Emphasis is on historical and contemporary contexts, major themes and theories crucial to successful development; execution of and leadership in advanced practice nursing.

Focus is also on the impact and evolution, certification, legal issues, ethics, best practices, standards, standardized procedures, prescriptive authority, and professional activities inclusive of advanced practice nursing roles.

Course Learning Outcomes:

Discuss the traditional and emerging advanced practice roles in response to local, state, national and global healthcare trends. (PLO 1, 4, 7)

Analyze historical and contemporary issues of education, titling, certification and licensure for advanced practice nursing roles. (PLO 3, 9)

Explore the functional roles of advanced practice nurses such as: Clinician, Educator, Researcher, Administrator, Entrepreneur, Consultant, and Leader. (PLO 1, 6, 9)

Debate the policies, social, financial, legal and ethical issues pertaining to advanced practice nursing. (PLO 5, 6)

Evaluate the influence of the theory of human caring as a worldview on the advanced practice role. (PLO 2, 8)

(editor's note:  this class is kicking my ass..but it's almost done!)

Week 1: Discussion Question 1 - The Future of Nursing: Leading Change, Advancing Health

Pamela Rudolph

posted May 5, 2022 10:26 PM

     For this assignment, I asked a friend to define the word ‘nurse’. He pulled up the following from the internet: “A nurse is a caregiver for patients and helps manage physical needs, prevent illness and treat health conditions. To do this, they need to observe and monitor the patient, record any relevant information to aid in the treatment decision-making.” (Yolanda Smith, 2021)While nurses today practice in settings such as hospitals, clinics, schools, major corporations, long-term care facilities and even the military, and while these nurses have varying levels of education, they all contribute to direct patient care. This information is partially accurate of the front-line nurse, however leaves out the ‘behind-the-scenes’ roles of many of today’s nurses. Today’s nurses are not only at the bedside, but work in areas such as administration, management, law and politics, informatics and technology, professors, and theorists. The role of today’s nurse is changing as rapidly as the health care needs of the patients they are charged with caring for.

     The health care needs of the people all over the world have become more complicated. Disease processes – both physical and mental are changing. Medications are being developed. Or discontinued. Nurses in all arenas must become more educated in order to not only care for patients (and at times their families and even themselves) but to lead and educate the nurses of tomorrow. According to the IOM’s report, “the role of nursing is expanding and nurses are expected to master technological tools and information management systems while collaborating and coordinating care.” (Institute of Medicine of the National Academies, October 2010)The report suggests that our federal government must get involved to allow nurses to achieve that higher level of education AND to allow them to perform to the fullest extent of their education – regardless of the state or locality they are employed in. For instance, a nurse who travels from one state to another, the ability to perform tasks necessary for patient care may be restricted by the barriers identified by today’s laws. In order for nurses to be prepared to effect change and help to advance healthcare, the barriers must be broken.

References

Institute of Medicine of the National Academies. (October 2010). The Future of Nursing; Leading Change, Advancing Health. Institute of Medicine of the National Academies.

Yolanda Smith, B. P. (2021, January 21). Roles of a Nurse. Retrieved from News Medical Life Sciences: https://www.news-medical.net/health/Roles-of-a-Nurse.aspx

Jean Watson's Theory of Caring - Can it be taught?

Pamela Rudolph

posted May 9, 2022 2:02 PM

     Jean Watsons Theory of Human Caring is the framework that students use throughout their nursing career – whether they realize it or not. Early in their studies, students learn that they will become the caregiver for patients, to manage their health conditions, and even teach them how to manage their health conditions independently. Throughout this education process we are taught about providing care. We are taught that we must practice loving kindness. The practice of caring, of kindness is one absolute in nursing, no matter the level we choose to practice. The practice of nursing is taught in a classroom just as science and medicine, but can the practice of caring?

     Can the act of caring and providing kindness be taught in a classroom setting? Can any human being enter the school of nursing and come out a caring, compassionate individual? Is sensitivity cultivated in a classroom or hospital, or are certain individuals just born with this ability? According to Current Nursing, “the formation of humanistic/altruistic system of values begins developmentally at an early age with values shared with the parents.” (Nursing Theories - Jean Watson's Philosophy of Nursing, 2020) But what if the child is brought up in a home with no humanistic values, or without one or both parents? Does this mean that this child cannot grow to become a nurse? Jean theorizes that the values are necessary for the nurse’s own maturation and are “mediated through one’s own life experiences”, “which then promotes altruistic behavior towards others.” (Nursing Theories - Jean Watson's Philosophy of Nursing, 2020) An effective, caring nurse is one that can promote health in the individual and the family. The answers to the above questions then would mean that throughout the early years of an individual, if the humanistic/altruistic values are obtained early in life or throughout the years prior to becoming a nurse, then this nurse will be able to practice effectively. “The practice of caring is central to nursing.” (Nursing Theories - Jean Watson's Philosophy of Nursing, 2020)

References

Nursing Theories - Jean Watson's Philosophy of Nursing. (2020, 10 26). Retrieved from Current Nursing: https://currentnursing.com/nursing_theory/

Relational Leadership Style

Pamela Rudolph

posted May 12, 2022 2:48 AM

     The Relational Leadership style definition reminds me of an APN I work with in our hospital. Staff nurses know that if they need help, have a question, or need a third set of eyes or hands, they can contact the NP, and prevent a rapid response to a patient’s declining condition. This style focuses on team collaboration, working together toward a common goal. In this example, the common goal would be to promote and maintain health of the hospital patient. Individuals in this setting may have different skill sets but collectively they bring an improved level of care to the sick. The Relational Leadership style is not only effective in a hospital setting, but may be found just as effective in a clinic. Together with the other staff members, including the on-staff physician, the patients can get not only diagnosis-specific care from the medical team but the skills and compassionate care of the nursing team.

     While the ANP will undoubtedly have to be compassionate, skilled in the physiology and pharmacology aspects of nursing care, the ANP will also be required to be technically competent, while continuing to focus on the needs of others, whether it be the needs of patients or the needs of those the ANP is leading. Also, while the ANP may choose one leadership style over another, the multitude of styles are needed with the ongoing changes in the healthcare industry to include “globalization, economic and technological factors, and the aging population.” (Joel, 2018) At any time in a nursing career, an ANP must evaluate and re-evaluate the leadership style that best fits their current environment.

Reference

Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development. Philadelphia: F. A. Davis Company.

The Advancement of Telemedicine: Thank You Covid!

Pamela Rudolph

posted May 14, 2022 2:29 PM

     The coronavirus pandemic of 2019 will certainly be remembered for many bad outcomes. Health disparities, medical staff burnout, deaths, even long-term chronic conditions that linger in its wake are historic. However, the pandemic helped spawn an advance in research and telemedicine. “Statistics show that more than half of US hospitals utilize some form of telemedicine.” (APN Healthcare, 2020) Innovations in healthcare technology have changed the face of advanced practice nursing and the communities it serves. Despite its’ popularity, telemedicine has both positive and negative effects on the health care community.

     There are several ways in which telemedicine is shaping the future for the better. Telemedicine today provides both audio and visual communication in a timely manner between clinicians and patients (or caregivers) and provides for timely clinical decisions. Virtual care often makes it easy for patients to receive medical care without waiting in lines. The ANP can spend more 1:1 time with patients who may not otherwise be able to make it to follow-up appointments following a hospitalization. This strengthens the provider/patient relationship and promotes better health for the patient. Patients with chronic conditions such as diabetes or cardiovascular disease can communicate virtually to update the ANP on their blood sugar levels as well as blood pressure readings and heart rhythms.

     However, all advances to telemedicine are not good. Physical exams are not possible, making some diagnoses impossible as the hands-on assessment cannot be made. Diagnostic tests, such as Covid-19 or flu swabs, cannot be done. There is a belief that telemedicine can cause an increase in mistakes on the part of patients and caregivers. The advanced practice nurse may be required to have knowledge of state laws and the scope of practice in both the state the ANP practices in as well as the state the patient might live in. This could limit the level of care an ANP can work in.

     Telemedicine is not always available in all areas, such as small rural communities. Perhaps future advancements in technology will allow these communities to afford telemedicine as it has a potentially significant role in the care of those areas medically underserved. The need for the advanced practice nurse will increase as the popularity of telemedicine grows in all communities.

References

APN Healthcare. (2020, August 11). How Telemedicine is Changing the Current Healthcare System. Retrieved from APN HEALTHCARE SOLUTIONS: https://apnhealthcare.solutions/articles/telemedicine-changing-healthcare-system/ Arnautova, Y. (2018).

Top healthcare industry trends to watch in 2018 and beyond. Retrieved from https://www.globallogic.com/insights/blogs/top-healthcare-industry-trends-to-watch-in-2018-and-beyond Torre, C. T. (2018).

Malpractice and the Advanced Practice Nurse. In L. A. Joel, Advanced Practice Nursing: Essentials for Role Development (p. 448). Philadelphia: F. A. Davis.

The struggle is real in North Carolina!

Pamela Rudolph

posted May 19, 2022 8:45 PM

     As of 2022, in the state of North Carolina an advanced practice nurse’s (ANP) scope of practice does not allow full autonomy. It requires the supervision of a physician. North Carolina also requires a Collaborative Practice Agreement (CPA) that requires the signature and date for each year the physician’s supervision is provided. (Nurse Practitioner Laws/Rules, 2020)

     The most important barrier to the NP is the limited level of practice regardless of education or practice. According to the Nurse Practice Act for Nurse Practitioners in the state of North Carolina, the APN’s scope of practice does not include full autonomy. Instead, the APN must work under the supervision of a physician and cannot perform even some basic evaluations and treatment functions that are limited only to physicians. North Carolina’s ANP scope of practice has not been updated or had restrictions loosened in many years. An increase in poorer rural populations is left without health care or healthcare cannot afford a primary care physician many miles away. (Nurse Practitioner Laws/Rules, 2020)

     “Our nurses are our best source of practitioners in our rural areas,” Senator Ralph Hise (R-Mitchell) said in a 2016 Joint Health and Human Services Oversight Committee meeting examining a bill (SB 695) to loosen regulations on registered nurses” (Balfour, 2018). Evidence has shown that by eliminating or loosening restrictions on their scope of practice as this bill suggests, APN’s help solve the issues regarding health care costs and physician shortages. Since 2010, 22 states have removed supervisory restrictions. In Arizona, for example, once these restrictions disappeared, the number of APN’s increased by 73% within 5 years. With the advancements that health care has made this century, the restrictions placed on North Carolina’s advanced practice nurses appears antiquated. Without the passage of SB 695 and as long as the various state-by-state regulations are in place, “every state border presents a potential barrier to access health care and health care professionals for consumers” (Kelli Harkey, Little, & Lazear, 2017)

     As of 2022 North Carolina does not require ANP residency hours with a supervising physician. While the ANP is a “highly trained professional,” (Balfour, 2018) no other training is required outside of the master’s degree education with the exception of completing 50 continuing education hours annually. I definitely would support a residency program as a requirement to independent practice, as I believe the ANP and the supervising physician should work closely together to not only establish a trust, but to learn the physician’s treatment and medication management style and expectations for the APN. Upon graduation and preparation for practice, I would not feel adequately prepared to assess and diagnose patients independently. Residency for an advanced practice nurse may benefit both to achieve the best patient outcomes.

     Mary Griff, North Carolina Nurses Association President once stated, “Nursing is the most trusted profession in the country, but opponents to this bill imply that nurses can’t be trusted to practice to the full scope of their training and education.” (Balfour, 2018)

References

Balfour, B. (2018, 2 1). Expanding Access to Medical Care in Rural North Carolina. Retrieved from The Civitas Institute: https://www.nccivitas.org/2018/expanding-access-medical-care-rural-north-carolina/

Harkey, K., Little, S., & Lazear, J. (2017). The Struggle for Full Practice in North Carolina. The Journal for Nurse Practitioners, 13(2), 131-137. doi:10.1016/j.nurpra.2016.08.025

Nurse Practitioner Laws/Rules. (2020, 11 12). Retrieved from North Carolina Board of Nursing: https://www.ncbon.com/practice-nurse-practitioner-nurse-practitioner-laws-rules

We definitely need quality APRN's as educators!

Pamela Rudolph

posted May 21, 2022 11:40 PM

     When discussing the subject of nursing, one subject that always comes up is that there is a definite shortage. The picture that comes to mind is the patient waiting to have a call light answered, to get needs fulfilled, to get timely care. However, this nursing shortage goes much farther than the bedside nurse. The nursing ‘shortage’ is a great upward spiraling challenge felt not only at the bedside, but at the managerial and educator level as well.

     Advance Practice Registered Nurses, while being four distinct types, all require advanced training, both in the classroom setting and the clinical setting. All four types - separated by The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education - require a master’s degree or higher to practice after graduation and training. However, with the shortage of the basic practice RN comes the shortage of Advanced Practice RN’s. (Katz, Hirsch, Fitzgerald, & Kantrowitz-Gordon, 2012)

     Colleges and universities are not able to afford to hire and retain qualified Advanced Practice Nurses (APN) as educators to meet the needs of today’s health care demand (Katz, Hirsch, Fitzgerald, & Kantrowitz-Gordon, 2012). Because these educational institutions cannot offer competitive compensation packages, the APN goes in the direction of the higher salaried clinical role. When there is a limited number of APN educators, the slope continues with the limited number of preceptors and clinicians as well. The number of available sites that employ preceptors is also limited.

     Why would an Advance Practice Nurse not want to be an educator, preceptor or clinical educator? Except for the idea that they are helping their fellow nurse, there is little incentive for nurses in this role. There is often a lack of formal teaching education as well as lack of compensation. There is little to no funding for training quality APRN’s. Rather, federal funding is spent on medical residency and training. Because there are so few APRN’s, there is little commitment to the time it takes away from their current role to act as preceptor or clinical educator (Katz, Hirsch, Fitzgerald, & Kantrowitz-Gordon, 2012).

     Evidence has shown that APRN’s are an effective health care provider and a cost-effective way to generate quality patient care outcomes. Nurse practitioners were created to fulfill the need for primary care providers. But to create a positive lasting change, it is important that federal funding is granted to the colleges and universities to compensate APRN’s as educators. This funding would lead to more qualified APRN’s, improved care in illness prevention and health promotion. Advanced Practice Nurses offer so much to the success of patient care not only in clinical and research settings, but also to the needs of the APRN students (Katz, Hirsch, Fitzgerald, & Kantrowitz-Gordon, 2012).

References

Katz, J., Hirsch, A., Fitzgerald, C., & Kantrowitz-Gordon, I. (2012).

Advanced Practice Nursing Education: Challenges and Strategies.   doi:10.1155/2012/854198. Retrieved from National Library of Medicine, PubMed Central

Week 4, Discussion 2 APRN Consensus Model 

     The implementation of the Census Model for APRN’s would align all states to license and regulate advanced practice nurses within the same scope of practice as well as standardize education in order for nurses to practice within their full scope. It would require all universities to carry the same accreditation, provide the same education and preparation for students in which to utilize within that scope. It would also require students to maintain the same certification. Without this Model in place, there is an inconsistent standard of practice among states.

     The Consensus Model for APRN’s was brought about for debate in hopes of obtaining a nationwide standard of practice among all advanced practice nurses to allow them to practice at their full educational potential to provide high-quality patient care, even when working across state lines. This Model, created for the four advanced practice roles: certified nurse anesthetist (CRNA), certified midwife (CNM), clinical nurse specialist (CNS) and certified nurse practitioner (CNP) would have a synchronous core education base, then branch off for these four roles. As these four roles progress, the education would once again focus on one of the six areas based on the diverse patient populations.

    While not all advanced practice nurses work across state lines, without this Model we may be highly educated to perform certain tasks or work independent, including prescription writing authority, delegation of access to the Prescription Drug Monitoring Program (Garrett, 2019). and independence from physicians, only to find the state we work in restricts these. “Some employers require NP’s to earn a post-master’s degree to demonstrate they have the skills and knowledge required for their role” (Doherty, Pawlow, & Becker, 2019).

References

Doherty, C. L., Pawlow, P., & Becker, D. (2019). What NP's Should Know About the APRN Consensus Model. AACN Bold Voices, 11(4), 16. Garrett, D. (2019).

Prescription Drug Monitoring Program, Antimicrobial Stewardship, Renewals and APRN Scope of Practice Decision Making Model. ASBN Update, 22, 12-13.

North Carolina - A Red State

Pamela Rudolph

posted May 28, 2022 10:47 PM

     As of 2022, North Carolina is one of eleven remaining ‘red’ states in the United States restricting practice for nurse practitioners (NP’s) (State Practice Environment, 2022). For licensure in this state, an NP must have a collaborative agreement with a supervising physician – which the physician has outlined in written instructions regarding indications and contraindications for prescribing drugs – along with a period review of these instructions. The prescribed drugs allowed by the physician must be included in the collaborative agreement (CA). Controlled substances (Level II to IV) can be included in the CA if: the NP has a DEA number, and it is included on the written prescription. They may be prescribed and refilled in accordance with the controlled substance laws of North Carolina. The NP may NOT prescribe for oneself; may not be prescribed to the supervising physician, anyone in the immediate family, one who resides in the same household or that the NP is having a relationship with (Prescribing Authority - Limitations on Nurse Practitioners, 2020). With the abuse and overuse of controlled substances by people today, and with the liability of this practice, this is one limitation I can understand and appreciate.

     Two other limitations within the red state of North Carolina are not guided by state laws but by Medicare regulations. A nurse practitioner can order Skilled Nursing care to a patient, but can neither admit the patient to the skilled nursing facility nor conduct the initial assessment. While the NP can conduct the Medicare required face-to-face visits to certify patients for home health services, the physician is required to complete a documented certification (Prescribing Authority - Limitations on Nurse Practitioners, 2020).

     By restricting nurse practitioners to the limitations of their scope of practice, so are we limiting any improved access to healthcare services, especially in urban and rural areas. The cost of healthcare will only continue to rise with the limitations. As proved in the ‘green’ states, it has been shown that giving nurse practitioners full practice authority and allowing them to utilize their abilities to care for patients reduces office visits, repetition of orders and avoids duplication of services and billing costs (Removing Practice Barriers for Nurse Practitioners, 2020).

     Until regulatory changes are made in the State Legislature in North Carolina, Medicare and Medicaid, private insurance companies and other payors will continue to pay higher rates for care that would then be passed on to the consumer, because the career long supervisory delegation of the nurse practitioner will not give patients the choices in healthcare that they otherwise would have (Removing Practice Barriers for Nurse Practitioners, 2020).

References

Prescribing Authority - Limitations on Nurse Practitioners. (2020, 11 12). Retrieved from North Carolina Board of Nursing: https://www.ncbon.com/practice-nurse-practitioner-nurse-practitioner-laws-rules

Removing Practice Barriers for Nurse Practitioners. (2020, April 8). Retrieved from Duquesne University School of Nursing: https://onlinenursing.duq.edu/blog/removing-practice-barriers-nurse-practitioners/ State Practice Environment. (2022, 04 15). Retrieved from

American Association of Nurse Practitioners: https://www.aanp.org/advocacy/state/state_practice_environment

Initially I'd planned to write about the lack of mental health care for our children in the county I live in.  We see children in the emergency room all the time for mental health evaluations.  Currently there is an 11-year old girl that has been here SIXTY days!  She cannot be placed in a facility because she isn't 12, apparently her parents  or foster parents don't care that she's been here that long, and the little girl has not played outside or seen sunshine since then.  That to me is abuse.  However, as I started to look at advocating for children, I was blown away by what I read about school nurses.  They advocate for each other, and try to advocate for the kids, however....read on...

Advocating for our APN AND our children!

Pamela Rudolph posted Jun 3, 2022 8:20 PM

(Initially I was going to write about the lack of mental health care for our children in Johnston County NC where I live. But after researching one other topic, boy it got to me. Took me back to when I was a child in the 1970's. I'm sorry this one is so long, but...)

     When we think of school nurse, perhaps we think of the nice lady in the white dress, sitting in her office prepared to talk to us about our upset stomach or the mean kid in class. One that would give us our inhaler after recess or check our blood sugar before lunch. There are cots lined up in her office for those that just need a few minutes away to feel better, or to wait for parents to pick them up. In the 1970’s, this nice lady did all of that and then lined up the entire elementary school student body to give us our required vaccinations and taught us how to brush our teeth. I still have scars from at least one of those events!

     The North Carolina School Nurses Association advertises that “Today’s school nurse is so much more than the stereotype of “ice, lice and Bandaids.” Their belief is that school nurses are “essential for healthy kids, healthy schools and healthy communities” (American Rescue Plan, 2021). However, how many students complain of being bullied, being hurt, even abused by their own parents, and feel they have no one to talk to? Have they been to see their school nurse, who will no doubt usually be there to advocate for every child? Perhaps they have TRIED to visit the school nurse, however found that there was a long, long line or even an empty office. In Johnston County alone, there are approximately 37,295 students in K-12 schools (Niche, 2022). There are 47 of these schools. They document that there is a student: teacher ratio of 15:1. However, there are only 21 nurses to fill the needs of all 37,295 students. 21 nurses to advocate for them, to create a sustaining and therapeutic relationship with them. To empower and support and listen to. That is a student: nurse ratio of 1,776:1 (Niche, 2022). How can these nurses, some who work in 3 or more schools at the same time, advocate for an individual student who may not show outward symptoms of needing a bandage, but may really need an adult to help them through bullying or abuse? Individual advocacy is valuable to those needing support.

     The federal government pours money into the schools for the education of our children. And each district has a budget. Perhaps the district needs to budget for more nurses in schools – more than one to just provide ice and a bandage – but perhaps to provide assistance the families for support for things like insurance or finding a primary care provider. Today’s school nurses not only provide personal care, albeit at a poor rate, but they are also responsible for managing complex chronic health problems, addressing mental health issues, promoting healthy nutrition and appropriate behaviors, even enrolling children and their families in health insurance programs. Their tasks became even more burdened when the COVID – 19 pandemic hit the US (American Rescue Plan, 2021). School nurses were then responsible for testing, tracking and finally vaccinating those children. It is not just the legislators that need to see and understand these numbers, but perhaps the school district AND the parents as well.

     Perhaps the School Nurses Association should be advocating for themselves as well! According to Nurse.org, a bachelor's degree is required to be a school nurse. The estimated average salary of a school nurse in 2022 is $52,546. In 2020, the average salary for the same nurse was $60,739, or $29 per hour. In North Carolina alone, the average annual salary is $45,483, or $21.87/hr., the lowest in the US (Jividen, 2022).

References

American Rescue Plan. (2021, April). Retrieved from National Association of School Nurses: https://www.nasn.org/advocacy/arp Jividen, S. (2022).

School Nurses Salary Guide. Retrieved from Nurse.org: https://nurse.org/education/school-nurse-salary/ Niche. (2022). Retrieved from Johnston County NC Schools Report Card.

Distinguishing the advanced practice nurse from medical counterparts

Pamela Rudolph

posted Jun 4, 2022 10:40 PM

In what ways can an APRN distinguish his or her role from other nursing roles and medical counterparts? Why might this be important?

     The need for more advanced nurses dates back to the mid-20th century when the barriers of access to healthcare existed just as the need for that healthcare increased. Because many physicians were deployed to Viet Nam during wartime, the need for primary care providers here in the United States increased (Joel, 2018). It was then that the role of the advanced practice nurse (APRN) was born to fill that void. Since that time, the need for this type of professional health care provider has grown exponentially. So much so that the role of the APRN has expanded to fill more specific healthcare needs (i.e. CRNA, CNM, NP and CNS).

     Much of the advanced nursing education for the four specific types of APRN is the same. APRNs have expanded roles for increasingly diverse populations and are able to function in roles other than in a traditional hospital setting. Therefore, each of the four types require additional education and training that sets them apart to further define each of the roles (Joel, 2018). Because the scope of practice for each of the APRN’s is not setting specific, their education varies according to the needs of the population he or she will serve (i.e. adult-geri, family, women’s, pediatric, neonatal, psychiatric, and even palliative and oncology). Herein lies how and why the advanced practice nurse is distinguished from their medical counterparts.

     While nurses and their medical counterparts share some of the knowledge in these areas, they do not share the same knowledge and skill set nurses have received. Preparation not only includes nursing knowledge and skills but also competency for their role and populations as well as education in pathophysiology and pharmacology, blending nursing and medicine (Joel, 2018).

Reference Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development (Vol. 7). Philadelphia: F.A. Davis.

   In every job, in every career, in every relationship, in every trip to the grocery store everyone is sure to be faced with conflict. Some conflict is healthy, as it allows us to make choices and either reap the benefits of the choice, or face the consequences of that decision.  Nursing is no different, except that nurses have to advocate for patients, too, so the decisions made during a conflict involve more than just the key players.        

     As I was riding to work today I heard the song, “Say” by John Mayer (see some of the lyrics after this writing).  After reading chapter 20 in Advanced Practice Nursing, this song made great sense and really stood out to me.  I am not a person who likes conflict.  I try to avoid most negative conflict because – that’s just who I am.  For now.  But I also enjoy saying what I need to say. Some people say that is a good attribute, others shake their heads because they never know what I will say.  No, it’s not Tourette’s syndrome.  It’s advocating for what I really feel passionate about.         

     In the summer of 2021, my employer, the University of North Carolina, was about to mandate the very controversial COVID – 19 vaccine.  They said it’s a “responsible decision to make to keep patients and staff safe” (WRAL, 2021).  Employees were required to get vaccinated or face being fired. They were given ample time to comply or receive an approved medical or religious exemption. This was one of the biggest dysfunctional conflicts I have been witness to.  I will not provide my commentary or opinion here, except to say that I am fully vaccinated.  Was it because of the mandate?  I can’t say.  However I was part of a vaccination clinic for our community so I have to remain unbiased.        

     According to the university newsletter, Carolina Together, “Executive order 14042 requires employees of federal contractors be vaccinated against COVID – 19 no later than January 18, 2022”  (Federal Vaccine Requirements for Employees, 2021).  This threw employees from all over the state, and in the hospitals, (and across the world) into a frenzy never seen before.  Why are they forcing employees to receive a vaccine?  Why are employees complaining?  It is a work requirement to have an influenza vaccine, the DTAP vaccine, the Hepatitis vaccine as well as a drug test before being considered for employment.  The university hospitals also have a “tobacco free” policy as well.  You save money on your insurance if you don’t smoke, you pay a premium if you do, and you cannot smoke on campus.  Rules are rules.  Employees have the right to work, as long as they follow rules.  Or they can move on, right?  How is this conflict advocating for ourselves or our fellow nurses, our families and patients?        

     Rather than asking to meet with the hospital board, or to fighting to change the order at the executive order, what does the staff do?  They protest.  On August 2, 2021 the staff at the location where I am employed decided they would picket outside the hospital to show their dismay.  Of the more than 1,400 people employed by this location, only 75 individuals were involved.  That is a very small number to affect change.  There is serious conflict here, in that 75 individuals were not able to affect any change.  Of the 12,800 total employees, not one was able to affect the change that they felt was important. One nurses stated, “when you have great, loyal people who love their jobs right now…When you strong arm people and you make them feel like they don’t matter…you take good dedicated employees and turn them into clock punchers, that’s not the kind of people you want working for you right now”.  The nurse offered no suggestions.  The nurse offered no solutions.  And very few left their positions at the hospital, even fewer lost their jobs for non-compliance.         

          “APN roles often entail role modeling, mentoring and teaching of nurses and, sometimes, other professionals” (Joel, 2018). Perhaps my prompt vaccinations and working in a vaccine clinic was just this.  While this is not a conflict nurses (or other employees) will encounter every day as a group, how individuals handle themselves during this type of conflict may affect the entire group.  Of the five kinds of responses per the Thomas-Kilmann Index, one can identify almost all of them in this conflict.  Except one.  Collaboration. 

Say – by John Mayer (only partial lyrics)

Take all of your wasted honor

Every little past frustration

Take all of your so-called problems

Better put ‘em in quotations

Walking like a one-man army

Knowing you’d be better off instead

If you could only

Say what you need to say.

Have no fear for giving in

You better know that in the end

It’s better to say too much

Than never to say what you need to say again

Even if your hands are shaking and your faith is broken

Do it with your heart wide open.

Say what you need to say.

References

Federal Vaccine Requirements for Employees. (2021, 10 25). Carolina Together. Chapel Hill, NC. Retrieved from https://carolina.together.unc.edu/2021/10/25/covid-19-update-federal-vaccine-requirements-for-employees

Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development. Philadelphia: F. A. Davis Company.

L. S., RN. (2021, August 2). NC healthcare workers protest vaccination mandates. (WRAL, Interviewer)

Mayer, J. (2008). Say.

WRAL. (2021, 8 2). NC healthcare workers protest vaccination mandates. Retrieved from https://wral.com/coronavirus/nc-health-care-workers-protest-vaccination-mandates/19806391

     When thinking of cultural diversity, one may think about groups of people that are based on race, ethnicity, and national origin. But cultural diversity also includes age as part of the definition. According to Joel (2018), Madeline Leininger was committed to developing a framework to assist nurses and other health-care providers to deliver care to all patients from diverse populations. Culturally competent care that evolved from “a commitment to improve the health of clients, families, and cultural groups to help them maintain or regain their health” (Joel, 2018). Healthy People 2020 and the Centers for Medicare and Medicaid Services has identified the elderly population as those 65 and older. With this rapidly growing group, they predict that by 2030, this population will account for 20% of the entire country. One in five Americans will be over the age of 65. The current Baby Boomers, or those born between 1946 and 1964 first turned 65 in 2011 (Jordan, 2020) .

For this reason, an advanced nursing specialization in Gerontology is in high- demand. Advanced Practice Nurses (APNs) can obtain a specialty certification to provide high-quality and evidence-based care to culturally diverse populations, and the elderly is one group that is vulnerable and socially disadvantaged. These APN’s must be competent in managing the aging process, including normal decline, delirium, depression, dementia and other cognitive changes. They must also be advocate for the patient as well as their families. One way to continue to remain competent in this culturally diverse population is to belong to special interest groups that offer collaborative research, practice and educational opportunities (Lynch J. P., 2018) “The most basic of all human needs is the need to understand and be understood. The best way to understand people is to listen to them.” Ralph Nichols, Author

References

Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development (Vol. 7). Philadelphia: F.A. Davis. Jordan, J. (2020, June 25).

65 and Older Population Grows Rapidly as Baby Boomers Age. Retrieved from United States Census Bureau: https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html Lynch, J. P. (2018, August).

Gerontology nurses mold care for senior population. Retrieved from Nurse.com: https://www.nurse.com/blog/2018/08/20/gerontology-nurses-mold-care-for-senior-population/#:~:text=APNs%20who%20specialize%20in%20the%20care%20of%20the,for%20this%20unique%2C%20sometimes%20vulnerable%2C%20population%20are%20endless.https://www.nurse.com

     When describing holistic care, I would explain that it is a type of care that uses modalities, treatments and a pathway to health by focusing on the mind, body and soul (including spirituality). Diet, exercise, and psychology also come into play here. Holistic care, especially in this case, should be used in conjunction with traditional medical care. This first-time mother’s symptoms of soreness, tiredness and the feeling of being overwhelmed are normal symptoms of pregnancy that could be exacerbated by the stress of losing her mother, and the relationship she is currently in which can cause psychological burnout.      

     Using Jean Watson’s Theory of Human Caring, several principles come to mind.   This first-time mother may benefit from one principle, called transpersonal, which includes authentic presence.  Sometimes, just having someone to listen to your concerns allows for a release of stress, whether the underlying problems are solved or not.  

     A caring occasion, as Jean Watson defines, is “when two people, each with their own background come together in a human-to-human transaction that is meaningful, authentic, intentional, honoring the person, and sharing human experience that expands each person’s worldview and spirit leading to new discovery of self and other and new life possibilities” (Watson, 2022). While the clinician in the example has also recently lost her mother, and while she can share her own feelings and understanding of this loss, she does not want to use this patient as a sounding board for her own feelings of grief.  She can, however, use it to let the patient know that she is not alone in her feelings.  It also may be a possibility that the clinician can relate to the “sore, tired and overwhelmed” symptoms of stress!       

     Multiple ways of knowing, another of Jean Watson’s holistic care principles, uses art as well as aesthetics, personal and cultural knowledge to give holistic care. The clinician may suggest journaling – both to write thoughts, plans, goals, and to do it as an art form by adding drawing, bullet points, and lists to keep track of her plans and goals with the upcoming birth of her baby. Writing her thoughts may be a such a release of stress, she can avoid bickering with her partner. Keeping track of her plans and goals will give her a mindset that is headed toward a more successful pregnancy and future as well.       

     Although not part of Jean Watson’s care principles, but holistic and important all the same, is nutrition.  This young (assuming) first-time mother may not realize how important nutrition is at this time of her life.  Nutrition is important not only for a growing baby, but a growing mother.  Proper nutrition can also help alleviate stress and fatigue. Perhaps she is not getting the protein, calories, calcium she needs.  Perhaps she is getting too much sugar or caffeine in her diet to allow her stress levels to wane and causing her hormones to get out of control.         

     A first-time mother would definitely benefit from Jean Watson’s teaching of the caring process.  The new mother does not typically know what to expect from the upcoming changes in her life, and beyond making sure that she and the baby stay healthy, the holistic ways of nursing are the forefront of this situation.  

Reference

Watson, J. (2022). Caring Science & Human Caring Theory. Retrieved from Watson Caring Science Institute:   

  https://www.watsoncaringscience/org/jean-bio/caring-science-theory

Cost containment and revenue vs effective prevent

     The conditions listed in Joel (2018) page 169 are conditions that are hospital-acquired. It is therefore important for any patient that happens to leave a hospital and develops one or more of them to return to the Emergency department and ultimately be admitted to the hospital for treatment. These are significant incidents (often called 'sentinel events'} that hospitals work to prevent, identify early and/or treat promptly and aggressively as most government payers hold hospitals responsible for the costs associated with them. In the hospitals and home health areas I have worked, both as a clinical nurse and alongside and APN, I have worked to prevent, have seen and treated many stage III/IV pressure ulcers and catheter-associated urinary tract infections (CAUTIs).

     Hospitals today, whether non- or for-profit, are concerned about these conditions as expenses and costs associated with their treatment and longer patent stays decrease revenue. For an advanced practice nurse (APN), who routinely works in this type of care environment is “generally not attuned to incorporating reimbursement variables into clinical decision-making for individual patients” (Joel, 2018). These clinicians are referred to as “payer-blind” (Joel, 2018) but still hold responsibility to the hospital to effectively treat the conditions.

     As an example, “vacuum assisted dressings for post-surgical wound healing is significantly more expensive than traditional dressings and would not be considered cost efficient…. that only addressed the expense incurred for dressings until wound healing is achieved” (Joel, 2018). Medications administered to treat a CAUTI are also not cost effective and can take several days or weeks to treat. An APN in a hospital setting may work closely with and educate staff to identify and monitor at-risk patients in pressure ulcer prevention. However, when this is not feasible, it is in the APN’s and the hospital’s best interest to treat these wounds aggressively, therefore the APN should have the knowledge of the current best practice for this type of condition (For example, a patient arrived on the medical unit after being in ICU for several weeks or months after being treated for COVID). For a CAUTI, the APN may want to review the considerations for needing the catheter and weigh risk vs benefit for having this internal device.

     Hospitals are aggressively monitoring these types of revenue draining, health impairing conditions and it would benefit the APN to get involved in prevention, treatment and education for all hospital acquired conditions to help contain these costs. It is especially important for hospital revenue, but from a clinical perspective it is even more important for patient advocacy.

Reference

Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development (Vol. 7). Philadelphia: F.A. Davis.

     Until recently, I considered opening an urgent care center of my own. I told myself if I ever won the lottery I would have a place of my own, then I would have the money to accept the patients I wanted, and not accept the patients I didn’t. I wanted to have the freedom and flexibility to provide the kind of care I believe patients deserve and be in charge of training those that were to work alongside me. However, after reading about starting a practice, the work involved in a successful business operation, the requirements for insurance billing and charges, codes, regulations, the law and malpractice issues I have changed my way of thinking.

     As an advanced practice nurse, I would prefer to be a formal employee, with some leverage in the kind of care I give patients. I want the benefits, the taxes withheld. And working for a teaching hospital as I do, I want the opportunity to clinically instruct, even if not in a formal manner. The hospital I am at has a nurse practitioner run clinic, and I feel I would be a great asset to its success.

     There is less responsibility with being able to do a certain job, during certain hours, and then going home. There is also something to be said for having my pay deposited in my bank account when it’s payday. I wouldn’t have to hire a payroll company this way. There is also something to be said for managing employees but not being responsible for their position. I’m also looking forward, at my age (57) to working less, and making more.

     There are times that I can offer my services to small groups, such as group homes or assisted living facilities. I have in the past performed nursing services for them to boost my income as well as provide community education and training. With a smaller business such as this, where I am the only employee, and have no billing or insurance issues, being an independent contractor makes sense. Paying for insurance, taxes, equipment becomes manageable when working from my home (or my car).

     While Joel (2018) indicates that “traditionally nurses have practiced as employees and not as independent contractors”, there are so many more opportunities for educated and highly motivated nurses to become entrepreneurs. However, they must pay attention to the legal and ethical practices and requirements they are subjected to in order to succeed in a private practice.

Reference

Joel, L. A. (2018). Advanced Practice Nursing: Essentials for Role Development. Philadelphia: F. A. Davis.

Access, Cost and Quality Environments for Advanced Practice Nurses

Pamela Rudolph, RN BSN

Department of Nursing, United States University

MSN560: Transitions in Practice: The Role of The Advanced Practice Nurse

Dr. Deborah Silverman

June 5, 2022

     Access to and the cost of high-quality healthcare are of utmost importance to all humans, whether they are in large cities, urban areas or even poor communities with little to no healthcare available. This access and cost is not only important to consumers but to hospitals, clinics, home health agencies and insurance companies as well as state and federal government payors. To solve some of the lack-of-access and high-cost-of-care issues, the healthcare industry continues to look toward the advanced practice nurses for their knowledge, skills, and evidence-based practice.

     Consumers and healthcare professionals are faced daily with the following questions and statements: “How satisfied are you with your physician?”, “Tell me about your hospital stay!”, “Would you recommend our office to your friends?”, “Use our prescription drug plan, it will save you money!”, “Patient satisfaction scores, keep ‘em up!”, ”It’s open enrollment time, talk to us about which plan is right for you!”, and, “I’m sorry but your insurance company does not cover these charges.”

     All of these questions and statements are heard by consumers and health care professionals every day. But what do they all mean, and why do they drive us crazy? Access, cost and the quality environment are the components that make up the health care triangle. One thing holds true: all are as equally important and necessary as the growing demand for health care continues. Consumers want and demand more access to quality healthcare and related services. Physicians look for access to insurance companies to cover costs of their services. And insurance companies demand access to quality measurement to ensure their patients are receiving high-quality health care at a low cost. If you have ever gone to a salon for a hairstyle or a carwash to get your car detailed for example, you demanded a quality service for a reasonable price. Healthcare is no different. While consumers are demanding more access to quality healthcare and related services, at a price they can afford, providers are struggling with availability for patients, reimbursement and regulatory requirements and limitations. And payors are demanding improved patient care, lower recidivism and standardized processes.

     Research has shown that consumers and society are not getting what they want or need from the health care system (Joel, p. 368). Hospitals continuously focus on improving patient outcomes, safety, and 30-day readmission rates in order to prove quality care to regulatory agencies such as the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services, who ensure its clients are receiving quality, cost effective care. Quality initiatives are the bases for quality efforts of these national healthcare organizations. These initiatives identify standards and expected outcomes for access, costs and quality measurement and public dissemination to ensure quality and cost effectiveness. In order to prove quality, to prove effectiveness and affordability, measurements are needed to understand where improvements are needed .     

     As far back as at least the 1960’s, there has been a serious need for providers in health care. Nurse practitioners came into play because a large number of US physicians were deployed to Viet Nam, leaving people without adequate access to healthcare. These APN’s received advanced education and given practice rights similar to physicians – except many states placed restrictions on these nurses. Today there are still restrictions in many states. Some are reduced practice restrictions while some states maintain full restriction, meaning the APRN must be supervised by a physician. As people live longer, as communities grow, and high-quality healthcare is in demand, so shall be the demand for advanced practitioners. The counter parts to nurses, also known as Physician’s Assistants, help to fill the gap that continues to widen – but the need remains.

     As the need grows for more specialty care, so does the need for more specialty guided APRN’s. The creation of the nurse midwife gives greater access to women in rural communities the choice in a more holistic health care for their well women needs as well as delivery of their babies. Certified registered nurse anesthetists answer the need for specialty care in surgical and critical care units, to fill the gap where Anesthesiologists find shortfall. Nurse practitioners assist in hospitals, clinics, doctors’ offices and many other areas to fill that need. The clinical nurse specialist often takes a more administrative role within a hospital setting, often managerial, educational, research-based and support positions. While this role does not fill a void where a physician might be needed but provides additional support for the rest of the nurses. Each of these roles also develops an additional specialty, making limited access to high-quality healthcare a thing of the past.

     With access to this high-quality healthcare comes the cost. Society demands this level of care at the lowest cost possible. They purchase insurance policies to help fray the cost of the healthcare and often look to their employer to provide that insurance. Those without insurance look to the state and federal government to foot the cost of this high-quality healthcare as well. Not only do patients expect the care and the low cost – but additional payors – insurance companies and state/federally funded programs – demand the same. They, too expect more care at a lower cost. They expect providers to help patients manage chronic illnesses. They also expect hospitals to keep patients from readmitting frequently – especially within 30 days of discharge.

     Other costs associated with high-quality healthcare also include pharmaceuticals. Often the best medication for a chronic illness is ‘the latest and greatest’ yet comes with a cost a patient cannot afford. This deters some from getting treatment they need. Until the medication is available in a generic, more affordable dose, the medication is one that comes at a premium. One that insurance companies do not cover, that hospitals do not stock. Patients look for alternatives – less expensive, less effective medications, home remedies, or skipping the treatment altogether. They also consider returning to the hospital for treatment. State and federal governments have long been trying to force pharmaceutical companies to cap the costs of these medications. Until agreements are reached, or costs are contained, the manufacturers often offer patients a limited quantity through direct contact, usually an online application or with help from their providers.

     Currently hospitals, health care agencies and provider offices do not bill insurance companies or the Centers for Medicare and Medicaid Services (CMS) for nursing services. Instead, this cost is built into the overall care of the patient. If patients have long wait times to been seen or poor access to a provider, their health could be placed in serious jeopardy. By allowing APRN’s to fill the need to health care access, patients will get healthier faster, will stay healthier longer, or perhaps avoid chronic illnesses altogether. Long term, this saves cost to not only consumers but to insurance companies and third-party payors as well. Advanced practice nurses bill for services, but at a much lower rate than physicians. When an NP can make face to face visits to home health and hospice patients rather than require a physician to make the visit, these agencies can bill for the service and receive the high-quality nursing care and assessment that would otherwise either be unavailable for long periods or not available at all. Home health and hospice agencies as well as skilled nursing facilities (SNF) are much smaller entities than provider offices and hospitals and welcome the ability to have greater care for their patients at a lower cost.

     As far back as even Florence Nightingale, nursing has been an evidence-based practice. How does one go about collecting evidence in which to base this practice? Quality measurements are at the forefront of healthcare. How do we know what we are doing is effective? How do we know what procedure works best on a group of patients? Graduate level nurses are very often involved in the collection of data. Hospitals collect this data as well in the form of patient outcomes, satisfaction scores and readmission rates, to name a few. CMS collects this data. SNF’s have shown decreased lengths of stays by collaborating with advance practice nurses. With APRN’s being more involved in the care of patients, “a large body of evidence has found that advanced practice nurses produce quality outcomes similar to or better than physicians” (Jennifer Thew, 2017). Why would this be? Nurses must be educated on the caritive nature of patients as well as curative nature. Graduate nurses also receive additional education on pathophysiology, psychology, and pharmacology as well as further education within their specialties. Nurses continue to educate and re-educate themselves in all areas of the advanced practice. The biggest barrier for advanced practice nurses is not a scope of practice, it is not a restricted practice, it is not the need. The biggest barrier continues to be the public understanding the role of the advanced practice RN – they are not ‘just nurses’ anymore.

     Without these constant quality measurements local and federal governments, legislators and even the healthcare community would not see or understand the success and benefits of integrating the advanced practice nurse into the current and growing need for high-quality healthcare. Access to quality, or even adequate healthcare will be difficult if not impossible to receive. Costs will not be contained, and research and development of the roles will not be successful. It is proven that “advanced practice RNs improve quality outcomes across the care continuum in multiple ways” (Jennifer Thew, 2017).

References

Jennifer Thew, R. (2017, June). APRNS Improve quality outcomes, cost of care. Retrieved from Health Leaders: https://www.healthleadersmedia.com/clinical-care/APRNS-improve-quality-outcoomes-cost-care?page=0%2C5 Joel, L. A. (2018).

Advanced Practice Nursing: Essentials for Role Development (Vol. 7). Philadelphia: F.A. Davis.