The Advanced Practice Nurse
In the United States there are over 267,000 advanced practice registered nurses (APRN”S) representing a dynamic, powerful force in our healthcare system. The advanced practice registered nurse (APRN) is a nurse with extended education in post-graduate education in nursing; prepared with advanced clinical and didactic education, skills, knowledge, and scope of practice in nursing. APRN’s play a vital, pivotal role in the future of healthcare as direct care; nurse practitioner’s (NP’s), clinical nurse specialists (CNS’s), certified registered nurse anesthetists (CRNA’s), or certified nurse midwives (CNM’s); and have a master’s, post-masters, or doctoral degree in their nursing specialty. Other APRN roles are; nurse educators (considered as direct care), and nurse informaticists, and nurse administrators (considered as indirect care). At South University, I am enrolled in the Family Nurse Practitioner (FNP) RN to MSN program. Here in is a compilation for this course (Role of the Advanced Practice Nurse); a contrast and comparison of the roles of the NP, nurse informaticist, nurse educator, and nurse administrator related to primary care, clinical practice, administration, education, and research; an examination of my specialty NP role with regulatory and legal requirements for the state of Florida and Michigan, professional organizations, required competencies and certification, and a predicated organizational setting of where I will work as a NP; and my determined leadership style, attributes with attainment and evaluation of missing attributes, a health policy issue identified from the Robert Wood Johnson Foundation with literature review of current policy, needed change and process, and how I would lead the change that would effect healthcare quality (“American Nurses Association, n.d.), (“National Council of State Board of Nursing”, n.d.).
Comparison and Contrast of Advanced Practice Roles
In 2004, the American Association of Colleges of Nursing (AACN) and member schools voted, endorsing the Position Statement on the Practice Doctorate in Nursing. This decision moved the current masters level of preparation necessary for APN’s to a doctorate degree level by 2015. Although there has been a progressing rapid transition, not all states and programs have been able to make this transition for various reasons. The four APRN roles (NP, CNS, CRNA, and CNM) must have education in all the nine Essential areas, and three graduate level courses in advanced physiology/pathophysiology, advance pharmacology (the three P’s), and advanced health assessment (“American Association of Colleges of Nursing”, n.d.).
The Consensus Model for APRN licensure, regulation, accreditation, certification, and education formed from the Joint Dialog Group in 2008. The group only addresses these four specialty APRN roles (NP, CNS, CRNA, and CNM) as being part of advanced practice nursing (APN), because they include direct care of patients; and believe, these roles should have regulatory recognition. APRN’s fulfilling these vital, pivotal roles in the future of healthcare, are at the forefront of providing preventative health care to the public and often are primary care providers (“National Council of State Board of Nursing”, n.d.).
All APRN’s are required to have research as part of their core skills as in the Institute of Medicine’s (IOM) Future of Nursing report. This report describes challenges and provides strategies to improve clinical education for APRN’s to assure that there are enough APRN”S available to fulfill the practice, educational, and research role. Evidence based practice and traditional research is necessary and has become an important factor with APRN’s direct clinical practice (Fitzgerald, Kantrowitz-Gordon, Katz, & Hirsch, 2012).
The role of a NP in comparison and contrast to a nurse informaticist, and nurse administrator differs in that the NP is in the direct care role, as well as a nurse educator. The nurse informaticist and nurse administrator roles involve indirect care. NP’s provide holistic care in various areas from; neonatal infants to adult gerontological patients; community services with academic NP faculty, retail health clinics, and nurse run clinics specializing in selected diagnoses or disease, as primary care and specialty providers working with a physician team (some states independently), and as an acute care NP’s in pediatrics, neonatal, intensive care, emergency departments. The fundamental nurse practitioner functions are, to treat and diagnose acute, episodic, or chronic illness including interpreting diagnostic test results and prescribing medicine according to the Bureau of Labor Statistics. (Gardenier, Todd & Davis, 2016).
Nurse educators specialize in education with leadership and development skills to teach nurses. “The AACN Preferred Vision of the Professoriate in Baccalaureate and Graduate Nursing Programs (2008) state that “courses in the nursing program will be taught by faculty with graduate-level academic preparation and advanced expertise in the areas of content they teach.” (“American Association of Colleges of Nursing”, n.d., p.1). Presently there is a shortage and a growing need for nurse educators to fill faculty and other education roles in the health care delivery system. Masters programs for nurse educators are designed to fulfill these needs. Nurses with a masters-degree may teach students or staff nurses, patients and their families, and various direct-care providers. The nurse educators’ preparation focuses on competencies in all nine Essentials areas. A nurse educator with a masters-degree builds on the baccalaureate knowledge further to teach graduate-level content in areas of pharmacology, physiology, pathophysiology, and health assessment. Nurse educators also need “additional content in an identified area of nursing practice and opportunities in the practice environment to integrate this new knowledge and skill into one’s nursing practice” (“American Association of Colleges of Nursing”, n.d., p.2).
The nurse informaticist fulfills the indirect care role; and is the science and practice integrating nursing, its knowledge and information, with management of communication and information technologies promoting health for people, families, and worldwide communities. A collaborate of leaders and advocates of organizations initiative of Technology Informatics Guiding Education Reform (TIGER) focus on nursing informatics responsibility and role. They developed a minimum set of competencies with practice in the current healthcare system, and recognize the need for leaders for the management of informatics. The entry level for a nurse informaticist is a master level of education (“American Association of Colleges of Nursing”, n.d., p.3).
Nurse administrators also are indirect caregivers, and are responsible for ensuring that hospital or other health care facilities operate in a safe cost effective manner. ”Nurse administrators in the present context, refers to the nursing head of any health care agency” (Nayak, 2015, p. 55). They can hold the job title of DON, or CNO. They strategically manage with regulating policies nursing personnel, patient care and facility resources. There are a variety of settings where nursing administration occur; from public sector to private settings, health care facilities large or small, corporate health care companies, academic settings, professional organizations, research and government agencies, military health agencies, and correctional institutions (“American Nurses Association” 2010).
The Family Nurse Practitioner Role
My individual APRN role that I will be fulfilling when I graduate from South University is the role of a FNP. I plan to fulfill my practice in this role in the State of Florida and the State of Michigan. The American Association for Nurse Practitioners (AANP) interactive map categorizes the scope of practice in America’s 50 states and territories by depicting legislative licensure and regulation requirements; full practice, reduced practice, or restricted practice. In the states of Florida, and Michigan, each fall into the category of reduced practice. This model requires delegation, supervision, or team-management by an outside health discipline in order for the nurse practitioner (NP) to provide patient care. Florida’s regulatory agency is the Board of Nursing and Board of Medicine, where as, Michigan’s is only the Board of Nursing. Florida requires a RN license, a graduate degree, and national certification, where as Michigan only requires an RN license and national certification. The Veterans Administration has recently approved full practice authority nationwide for NP’s as of December 13, 2016. This is a major breakthrough for NP’s! NP’s are encouraged, and looking forward to working with the present Trump Administration to effect this change for NP’s in all 50 states (“American Association of Nurse Practitioners”, n.d.).
Surprisingly, Florida has 17 professional nurse practitioners organizations, and Michigan only has one, the Michigan Council of Nurse Practitioners (MICNP) – “MICNP: Nurse Practitioners working together with one voice” (MICNP, n.d.). Florida’s NP’s are governed by the Nurse Practice Act, and Michigan is governed by the states Nursing Regulations. AANP is the leading advocate for NP’s in our country. The requirements for membership are annual dues of $135, successful completion of a NP program, and or maintenance of national certification. Members shall have rights to vote in state and national elections, and the NP must be in good standing one year before nomination of a state or national office. Benefits include; free access for CEU’s, discounted certification application fee, exclusive liability rates, job and career service, scholarship/grant opportunities, and more (“American Association of Nurse Practitioners”, n.d.).
As recommended by a nurse practitioner instructor from Nova University here in South Florida; with my extensive experience in the Intensive Care Unit (ICU) and national certification in critical care, my previous experience as an emergency medical technician, and my occasional float time to the ED, and a Family Nurse Practitioner degree from South University, I would make a good fit to fulfill the Nurse Practitioner role for the Emergency Department. In addition, starting with an experienced NP preceptor, an internship would give me a strong start. Also, I have experience with working codes in the ICU, respiratory failure and ventilators, renal failure, CVVHD, hypothermia, chest pain, and many other serious life threatening conditions. “NP’s and PA’s are increasingly common in U.S. and Canadian EDs” (Klauer, 2013, p. 134).
My Leadership Attributes of the Advanced Practice Role
I took the “What’s Your Leadership Style?” (Cherry, 2016, p. 1) quiz to learn more about my weaknesses and strengths as a leader. What I found out is that I have a democratic leadership style. Democratic leaders have a participative leading style, encouraging open communication with staff participating in decisions. This leader accepts input from the group or an individual in the group when solving problems or making decisions. A democratic leader retains the final say on decisions when the choices are made. Group members under this style of leadership tend to be motivated and encouraged. More accurate effective decisions tend to be made with input coming from members with specialized expertise and knowledge giving a more solid basis for decision-making. The staff is given responsibility, feedback and accountability regarding their performance. The democratic style is similar to the transformational style of leadership, this fits into the type of leadership I believe I lean toward using. Both of these leadership styles, is based on building relationships. The democratic leader places a focus on quality improvement of systems or processes, rather than on mistakes of the individual staff member. Transformational leaders are charismatic, motivating staff by building relationships and sharing mutual vision and mission. They convey staff respect and loyalty by letting staff know they are important; being a master at helping, praising, and encouraging people do things that they did not think they could do. As I mentioned, before I took this quiz, I believed I tended to be more of a transformational leader. Good leaders use all three types of leadership styles; authoritative, if a staff member lacks knowledge about a procedure, democratic, for those who understand their role in certain tasks, and delegative, if the staff knows more than the leader about a certain task (Cherry, 2016), (Frandsen, 2014, p. 1).
Graduate nurses practice leadership in four domains; clinical practice, nursing profession, system level, and health policy. Additionally, there are many personal attributes that are necessary for successful leadership. APN’s need excellent communication skills; being able to articulate well in speech and writing to get one’s point across, to listen well, hear, and understand another’s point of view… staying connected with others. A good leader is strong in vision and commitment of giving of oneself personally and professionally, listening to ones inner voice, balancing private and professional life, planning ahead to make change happen, and engaging in self reflection. They develop their own style and get involved, set priorities managing boundaries, uses technology engaging in lifelong learning, and keeping a sense of humor. They are involved in risk taking by willing to get involved at any level, demonstrating self-confidence and assertiveness, being creative, able to see the big picture with a good sense of timing, and able to cope with change. They respect cultural diversity, willing to share power, mentoring and giving empowerment to others, and desires to build a team with alliances (Hamric, Hanson, Tracey, & O’Grady, 2014).
When analyzing my own personal attributes, I realize that I naturally have many of the above characteristics. I listen well to others, and work to be open to understand others point of view. When I lead, I have a strong vision of what needs to be accomplished; looking at the big picture. I give of myself personally and professionally, listening to my inner voice. I work at planning ahead to make change happen, engaging in self-reflection, balancing personal and professional life. I do develop my own style, but I do need to work on setting boundaries for myself and others, being more assertive to set boundaries so aggressive, rude people do not take advantage of my kind nature. I do use technology, am involved in lifetime learning, and do try to keep a sense of humor. I could use a sense of humor more, and not be so serious…to keep things on the light side. I do have to work more at assertiveness and confidence when communicating with others, or even when challenging others when I believe they need to be challenged. Timing is also something I need to work on, being consistent with being on time for appointments. I do respect cultural diversity; I am willing to share power, mentor, and give empowerment to others (Hamric, et al., 2014).
Health Policy Issue
After visiting the Robert Wood Johnson Foundation, I identified the health policy issue about dietary guidelines for Americans. The current policy is that; “Every five years the Federal Government publishes recommendations intended to shape peoples’ diets based on the latest research” (“Robert Wood Johnson Foundation”, 2015 p. 1), in accordance to the “1990 National Nutrition Monitoring and Related Research Act” (“Robert Wood Johnson Foundation”, 2015 p. 1). This Act requires the Department of Agriculture (USDA) and Health and Human Services (HHS) to publish a joint report for the Dietary Guideline for Americans at least once in a five-year period. The 2015 Dietary Guidelines are heavily informed by the 2015 Dietary Guidelines Advisory Committee’s (DGAC) Scientific Report, that analyzes the latest in nutrition science since 2010 to come up with food-based recommendations for public health. The issue is, that the secretaries of USDA and HHS are not obligated to accept every recommendation that the DGAC submits. And, the DGAC guidelines are extremely influenced by a heavy amount of lobbying efforts forming the basis of federal nutrition policies for the National School Lunch Program (serving 31 million children per day), the Supplemental Nutrition Assistance Program (SNAP), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The DGAC summary report had two major realities; the first is that almost half of American adults have a chronic preventable disease, and two-thirds are overweight or obese because of diet, life style behaviors, and inactivity. The second is that these lifestyle behaviors are influenced strongly by social, personal, environmental settings, and organizational systems. This meant that health outcomes could significantly improve with more physical activity and a better diet. In addition, there were four U.S. congressional subcommittees who weighed in restricting the guidelines. Two House subcommittees added language that any changes to the 2010 Guidelines be backed by strong evidence from the Nutrition Evidence Library. Two Senate subcommittees added language limiting the guidelines to just nutritional and dietary excluding physical activity or economic barriers (“Health Affairs – Robert Wood Johnson Foundation”, 2015) (Goldman, 2015 p. 1).
What needs to change is all the bureaucracy (non-elected government officials), lobbying, complication of the subcommittees, and a simplification of the process. “Because the guidelines ultimately affect food-buying decisions worth billions, if not trillions, of dollars and the health of Americans, they are often heavily lobbied by large corporate and smaller non profit interests alike” (“Health Affairs – Robert Wood Johnson Foundation”, 2015, p. 4). Is it not always about the money? I see this as too many hands in the cookie jar. The China Study is the most comprehensive study on nutrition ever. I believe that if Americans changed their diet to a non-GMO diet, to organic foods, to one without processed foods, the health of our nation would improve. “By any measure, America’s health is failing. We spend far more, per capita, on health care than any other society in the world, and yet two-thirds of American are overweight, and more than 15 million Americans have Diabetes. We fall prey to heart disease as often as we did thirty years ago. The war on cancer, launched in the 1970’s, has been a miserable failure. Half of all Americans have a health problem that requires taking a prescription drug every week, and more than a million Americans have high cholesterol” (Campbell & Campbell, 2006, p.418). “It is important to establish that the first strategy to treat atherosclerosis is to modify lifestyle habits, focusing on the beneficial properties of specific nutrients. In the last decades, epidemiological, clinical and experimental studies have demonstrated that diet plays a central role in the prevention of atherosclerosis” (Torres, Geuvara-Cruz, Velazquez-Villegas, & Tovar, 2015, p. 408).
What I could do is write my political leaders, even our president, and meet with them if possible; to give them evidence based studies that proved how nutrition and lifestyle can change the health of our nation, and saves billions of wasted dollars and lives. I could join my nursing associations to enact change with other nurses who would fight the same cause. I would ask our president and other influential leaders to launch a nationwide campaign for education, for the public on the benefits of good nutrition and a healthy life style. I would ask our president to change and un-complicate the process for the American Dietary Recommendation Guidelines so that a simple, common sense approach, and solution could be attained. I would spread the word on a grass roots basis in my circle of influence; my family, where I work, my church, and friends and those I meet. Obviously, our health care system is broken, and is a major issue in this country. This trillion dollar healthcare industry is not producing improved patient outcomes as a whole, and by focusing on healthy nutrition and lifestyle, this would save trillions of dollars, millions of lives and suffering through the plant-based diet God, the creator of our bodies recommended. God said, Behold, I have given you every herb bearing seed, which is upon the face of the earth, and every tree, which is the fruit of the tree yielding seed: to you it shall be for meat (Genesis 1:29 KJV).
In conclusion, with over 267,000 APRN”S in the United States as health care leaders representing a dynamic, powerful force in our healthcare system, we have the potential to unlock the current healthcare dilemma that is costing Americans trillions of dollars, many lives, and an enormous amount of needless suffering. Through the leadership, knowledge, education, skill, research, legislative and policy changes, and the professional organizations of APN’s we can deliver quality breakthrough health to not only our country, but throughout the world. I have heard it said of nurses; it takes a nurse to save a life.
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Veterans gain better access to care: Nurse practitioners applaud VA’s rule. (2016). Retrieved from https://www.aanp.org/press-room/press-releases/173-press-room/2016-press-releases/2048-veterans-gain-better-access-to-care-nurse-practitioners-applaud-va-s-rule