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Nursing Outcomes in Advanced Practice Michelle Beauchesne, DNSc, RN,CPNP Fellow, National Academy of Practice Fellow, American Academy of Nurse Practitioners.

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Presentation on theme: "Nursing Outcomes in Advanced Practice Michelle Beauchesne, DNSc, RN,CPNP Fellow, National Academy of Practice Fellow, American Academy of Nurse Practitioners."— Presentation transcript:

1 Nursing Outcomes in Advanced Practice Michelle Beauchesne, DNSc, RN,CPNP Fellow, National Academy of Practice Fellow, American Academy of Nurse Practitioners Associate Professor & PNP Coordinator Northeastern University, Boston, MA, USA

2 Engage Experience Excel

3 Boston February 6, 2009

4 What are outcomes? End result of care Measurable change in health status or behavior A desired condition A measurable patient goal

5 Nursing Outcome The measure or status of a nursing diagnosis at points in time after a nursing intervention ICNP® 2001

6 Why do we need outcome data? Accountability Regulatory bodies Evidence Based Practice/ Guidelines Consumer demand Policy driven Societal perspective

7 2 important questions What is to be measured and why? What result are you seeking and when?

8 What? Issues in Defining Nursing Benchmark data Not sensitive to nursing care Team practice Whole vs individual Bundling costs and resources All inclusive

9 Next : How do we define advanced practice?

10 Definition: Advanced Practice Nursing Nurse Practitioner/Advanced Practice Nurse is 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. International Council of Nursing Nurse Practitioner/Advanced Practice Network (ICNNP/APN)

11 The Problem A recent survey among 18 countries, conducted by the International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) of the International Council of Nursing identified: 14 different titles existed for the APN role Majority (75%) had formal recognition of the APN role 58% had formal APN education programs 52% had licensure requirements, showcasing developing acknowledgement of the APN as an official advanced role for nursing practice

12 Examples of Early Advance Practice Nursing Outcome Research Florence Nightingale: Modern Nursing First outcome data First nurse managed Hospitals First environmentalist First public health nurse Do No Harm Cheaper to keep well than cure illness!

13 Early Nursing Outcome Research Informs Policy Lillian Wald (1867-1940) Visiting Nurses Service 1893 Henry Street Settlement House 1895 Nursing Insurance Partnership 1909 Federal Children’s Bureau 1912 Esther Lucile Brown ( 1898-1990) Social Anthropologist PhD Yale 1929 Russell Sage Foundation 1930 “The Brown Report” 1948, ''Nursing for the Future''

14 Mary Adelaide Nutting 1858-1948 World's First Professor of Nursing 1910 Teachers College at Columbia University in New York City 1918 Shared with the Rockefeller Foundation her dream of seeing basic education for nurses established in universities Resulted in formation of the Committee for the Study of Nursing Education, which released the 500-page study Nursing and Nursing Education in the United States in 1922. (aka The Goldmark Report for its author, Josephine Goldmark) Authored with Lavina Dock, 4 volume History of Nursing

15 All before the Vote!!!!!

16 American Nurses Association (ANA) Congress of Nursing Practice, 1974 Definitions of Advanced Practice Roles: Nurse Anesthetist Nurse Midwife Clinical Nurse Specialist Nurse Practitioner

17 Historical Review Sister Mary Bernard St. Vincent’s Hospital Erie, PA 1st Nurse Anesthetist 1877 Agatha Hodgins 1 st NA program Ohio 1914 AANA 1931 Mary Breckenridge British-Trained Nurse-Midwife Frontier Nursing School and Service 1925 AANM 1929

18 Frances Reiter 1943 “Nurse-Clinician” Designated a nurse with advanced clinical competence

19 Clinical Nurse Specialist Adelaide A. Mayo, editor American Journal of Nursing 1944

20 1st Clinical Nurse Specialist Program Hildegard Peplau Rutgers University, New Jersey 1954 Psychiatric Nursing- Master’s Level NACNS 1995

21 1st Nurse Practitioner Programs Pediatric Nurse Practitioner Loretta Ford & Henry Silver University of Colorado 1965 NAPNAP Adult/Family Nurse Practitioner 1971 AANP ACNP Neonatal Nurse Practitioner 1977 Acute Care Nurse Practitioner 1995 Adult 2005 Pediatric

22 APN Outcome Studies CRNAs Alice MaGaw 1899 1 st outcome study Northwestern Lancet CNMWs UCSF PEW Health Professions 1998 14 recommendations to improve practice CNS Dayhoff & Lyon 2001 CNS defined by role

23 1 st NP Outcome Study The University of Colorado PNP Demonstration Project 1965 Purpose: To prepare professional nurses to provide comprehensive well-child care as well as manage common childhood health problems. Emphasis: Family dynamics and community cultural values. Focus: Shift from care of medical illness to a strong family oriented health promotive approach.

24 Factors Influencing US Nurse Practitioner Development Nurse Training Acts Public Health Nursing Primary Care Physician Shortage Trend Toward Medical Specialization Consumer Movement Women’s Movement Needs within the population Nursing profession Health-care delivery system Emphasis on primary health care

25 Landmark Outcomes Study Committee of the Secretary of Health, Education, and Welfare Report, 1971 Purpose: to study extended roles for nurses to evaluate feasibility of expanding nursing practice

26 Significant Conclusions Extending the scope of the nurse’s role was essential to providing equal access to health care for all consumers. Need to establish innovative curricular designs in health science centers with increased financial support for nursing education. Need to advocate for commonality of nursing licensure and certification, including a model nursing practice law suitable for national application. Need for research related to cost-benefit analyses and attitudinal surveys to assess impact of new role.

27 Loretta Ford 1991 “The nurse practitioner movement is one of the finest demonstrations of how nurses exploited trends in the larger health care system to advance their own professional agenda and to realize their great potential to serve society.”

28 Challenges in Outcomes Research 40 years later Ambiguity over role definition still exists Historically lack of unity in requirements for entry into programs Variations in degree received Debate over setting for and length of program Certificate, MS, now DNP Scope of practice (State vs Federal in US)

29 Standardization of Educational Preparation for Nurse Practitioners 1979 - 124 certificate programs, 74 master’s 1990 - 11 certificate programs, 84 master’s programs 2005 - 2 certificate programs 400+ master’s 2007 - 11 DNP programs 2015 - DNP all NP programs

30 Standards & Guidelines AACN Masters Essentials (1996) ` To establish a unifying framework for APN curricula through the identification of a “common educational core” Advanced Nursing Practice:Building Curriculum for Quality NP Education (2002)

31 Common Features of APN Graduate Education The Graduate Nursing Core: generic to all master’s nursing degrees The Advanced Practice Nursing Core: generic to all advanced nursing practice The specialty role core specific to each APN role

32 Graduate Core Curriculum Content I. Research II. Policy organization and financing of health care a. Health care policy b. Organization of the health care delivery system c. Health care financing III. Ethics IV. Professional Role Development V. Theoretical Foundations of Nursing Practice VI. Human Diversity and Social Issues VII. Health Promotion and Disease Prevention

33 APN Core Curriculum Advanced Health/Physical Assessment Advanced Physiology/Pathophysiology Advanced Pharmacology

34 Specialty Curriculum Process of Clinical Decision Making Complex or Advanced Nursing Interventions Health Promotion/Disease Prevention Epidemiology Role Differentiation Interpersonal and Family Theory

35 APN Curriculum Framework and Competencies

36 National Organization of Nurse Practitioner Faculties (NONPF) 2006 Seven Domains of Practice 1.* Management of Client Health/Illness Status 2. The Nurse-Client Relationship 3. The Teaching-Coaching Function 4. Professional Role 5.* Managing and Negotiating Health Care Delivery Systems 6. *Monitoring and Ensuring the Quality of Health Care Practice 7. Cultural and Spiritual competency

37 Sample NP Skills & Functions screening physical and psychosocial assessment management of common health problems follow-up continuity of care health promotion problem-centered services identification and mobilization of resources health education client and group advocacy * All are aspects of Primary, Secondary, Tertiary Care

38 Avedis Donabedian’s Quality of Care Model Structure Process Outcomes Supports federal government’s sponsorship of Professional Standards Review Organizations (PSRO's) & Continuing Quality Improvement (CQI) Science, Vol 200, Issue 4344, 856-864 Copyright © 1978 by American Association for the Advancement of Science

39 Quality of Care The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge Institute of Medicine (IOM) 1990

40 Challenges to Nursing Outcome Research Patient autonomy Multiplicity of individual’s health problems Nonclinical characteristics Multiplicity of providers Unknown time between interventions and outcomes Lack of baseline measurements Complexity of variables

41 Additional Problems Relative insensitivity of outcomes Final outcomes not known until too late Outcomes can be influenced by outside factors Information about outcomes not readily available Few lists of valid effectiveness criteria and measurements Nugent & Lambert 1997

42 Variance in Outcomes Not met at all Met later than expected Met ahead of time Variance Positive Negative Classification of Variance System Provider Client Murray & Anderson 2000, Murray & Lindgren 2001

43 Questions to guide outcome research Which outcomes are most important? To whom are they important? How are they defined? How should they be measured? Who is accountable for achieving them? Minnick 2001

44 Outcomes Measures ( Indicators of Outcomes) Observation Description Quantification

45 Types of Outcomes Physiological Heart rate Weight Perceptual Satisfaction Symptom control Quality of life Well being Psychosocial Attitude Mood Cognitive Knowledge Understanding Functional ADLs ROM Fiscal Cost Behavioral Compliance Motivation

46 General Outcomes Length of stay Resource use Costs Patient satisfaction Technical skills

47 Inventory of Patient Outcomes Symptom control and change in symptom severity. Functional status. Knowledge of condition and treatment. Patient satisfaction with care. Unplanned emergency department visits. Unplanned hospital readmissions. Strength of treatment alliance. International Council of Nurses (2001) International Classification for Nursing Practice

48 Clinical Outcomes Need to adjust for risk factors Baseline status Clinical status Treatment Setting Environment

49 Variables affecting patient outcomes Socio­economic factors Family support Age and gender Quality of care provided by other professionals and support workers

50 Continuum of Outcomes Too global or general Difficult to measure or link them to prior action Too specific or specialized Limited meaning or generalizability

51 Principles in Determining Outcomes Must be measurable Must relate to care process/intervention Must be realistic Must be measured within accessible time span Must describe risk Must consider cost Chosen parameters must be accurate and specific to care

52 Consider Cost Minimization Benefit analysis Consequences Utility Underutilization Direct Indirect Opportunity

53 Gold Standard in Early APN Outcome Research Comparative outcomes Measured against physician care Equivalent Superior

54 US Comparative Studies Brooten et al 1986 Mundinger 2000 Health Resources and Service Administration (HRSA) Bureau of Health Professions (2000) CNS & NP workforce reports US Congress Office of Technology Assessment 1986

55 International Comparative Studies Australia Horrocks, Anderson & Salisbury (2002) Chang et a (1999) United Kingdom Kinnersley et al (2000) Sakr et al (1999) Netherlands Laurant et al (2004)

56 Reviews of categories of indicators for outcomes Hegyvary 1991 Clinical Functional Financial Perceptual Irvine et al 1998 Complication Prevention Clinical outcomes Knowledge Functional health Cost of care Patient satisfaction

57 Classification of Outcomes Lang & Marek 1990 Physiological Psychological Functional Knowledge Symptom control Home maintenance Pt satisfaction Safety Nursing diagnosis resolution Frequency of service Cost & rehospitalization Well being Goal attainment

58 Sources of Measurement: Common Data Sets Administrative data Medical records Discharge summaries Surveys Electronic medical records Patient/family reports Clinical practice guidelines/critical pathways Standardized Data Sets JCAHO CONQUEST AHRQ HEDIS

59 APN Outcomes and Acute Care Setting Large body of literature >disease/medical based > physiological measures >skill/function based

60 Systematic Reviews of Nursing Outcome Research Bourbonniere & Evans 2002 Cunningham 2004 Kleinpell 2001

61 Limitations in APN Studies Lack of methodological rigor Use of variable measurement strategies Lack of specific health related outcomes Use of physician as comparative group Heterogeneous outcomes Lack of economic analysis

62 All Conclude: Need Nursing/APN­Sensitive Outcomes Changes in health status upon which nursing/APN care has had a direct influence

63 Nursing Outcome Goals Often directed toward cost containment >hospital based, < community based Rarely directed toward understanding scientific basis for clinical practice Rarely examine underlying relationship between outcomes and care

64 Beyond comparative value outcomes of APNs Unique contributions of APNs Income “Value added” Mundinger 2000 Ryden et al 2000 Wong et al 2000

65 Example APN value added skills Health education integral to care Disease prevention/health promotion Teaching/counselling/listening Coordination of care Community resource access Partnerships with patients/families Holistic care in a family social context Added ‘nursing ingredient’ to APN care (Plager & Conger 2007)

66 Nurse Sensitive Outcomes of Practice ANA 1996 Set of Nursing Indicators Johnson & Maas 1997 Nursing Outcomes Classification Generic Nursing CNS Literature

67 Ingersoll et al (2000) Nurse Sensitive Outcomes of APN Practice 10 indicators Pt satisfaction Symptom resolution/reduction Compliance/ adherence/ cooperation Knowledge of patient/family Quality of life Perception of being well cared for Trust in provider Collaboration among providers Care provider recommendations Frequency/type procedures ordered

68 How do we capture both the art and the science of high level caring at all levels of nursing?

69 The Blended Art & Science of APN Cunnngham (2000) posits, “How to measure, as Benner (1984) suggests, the exquisite skill in clinical judgment that comes from ‘knowledge embedded in practice’ which may be a deciding variable in APN care Bourbonniere & Evans (2002) use the term ‘contextual thinking’ to denote the APN’s high level of data synthesis

70 Conclusion: What is the importance of Nurse Sensitive Indicators & Outcomes?. Demonstrate that nurses at all levels provide safe, quality, and cost effective care. Provide strong support for appropriate allocation of health care resources. Continue to measure the Art of Nursing as well as the Science of Nursing. Make Nursing Visible.

71 Future Challenges and Opportunities

72 APRN Regulatory Model 2008 4 roles 6 population foci Education, certification, and licensure must be congruent in terms of role & population foci. Specialties can provide depth in one’s practice within the established population foci.

73 Doctorate in Nursing Practice (DNP) Although the current masters and PhD programs in nursing are critical to the future of the profession and are evolving to keep pace with new demands, they do not fill the growing need for expert clinical teachers and clinicians. Informational shifts, demographic changes, growing disparities in healthcare delivery and access, and stakeholder expectations are all creating new demands on the nursing profession. The practice (also called clinical and professional) doctorate, with a focus on direct practice and healthcare leadership, offers nursing an exciting opportunity to meet these demands.

74 22 National Nursing Organizations Join Together to Commission a Study of the Impact of Advanced Practice Registered Nurses on Healthcare Quality, Safety, & Effectiveness since 1990 24/9/2008 The Tri-Council for Nursing Robin Newhouse, PhD, RN, CNAA, BC, CNOR University of Maryland & Johns Hopkins University.

75 “Nursing is not second class medicine but first-class health care” Loretta Ford


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