Presentation on theme: "Nursing Outcomes in Advanced Practice"— Presentation transcript:
1 Nursing Outcomes in Advanced Practice Michelle Beauchesne, DNSc, RN,CPNPFellow, National Academy of PracticeFellow, American Academy of NursePractitionersAssociate Professor & PNP CoordinatorNortheastern University, Boston, MA, USA
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 ProblemA recent survey among 18 countries, conducted by the International Nurse Practitioner/ Advanced Practice Nursing Network (INP/APNN) of theInternational Council of Nursing identified:14 different titles existed for the APN roleMajority (75%) had formal recognition of the APN role58% had formal APN education programs52% 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 NursingFirst outcome dataFirst nurse managedHospitalsFirst environmentalistFirst public healthnurseDo No HarmCheaper to keep well than cure illness!
13 Early Nursing Outcome Research Informs Policy Lillian Wald ( )Visiting Nurses Service 1893Henry Street Settlement House 1895Nursing Insurance Partnership 1909Federal Children’s Bureau 1912Esther Lucile Brown ( )Social Anthropologist PhD Yale 1929Russell Sage Foundation 1930“The Brown Report”1948, ''Nursing for the Future''
14 Mary Adelaide Nutting 1858-1948 World's First Professor of Nursing 1910Teachers College at Columbia University in New York City1918 Shared with the Rockefeller Foundation her dream of seeing basic education for nurses established in universitiesResulted 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 (aka The Goldmark Report for its author, Josephine Goldmark)Authored with Lavina Dock, 4 volume History of Nursing
16 American Nurses Association (ANA) Congress of Nursing Practice, 1974 Definitions of Advanced Practice Roles:Nurse AnesthetistNurse MidwifeClinical Nurse SpecialistNurse Practitioner
17 Historical Review Sister Mary Bernard St. Vincent’s Hospital Erie, PA 1st Nurse Anesthetist 1877Agatha Hodgins1st NA program Ohio 1914AANA 1931Mary Breckenridge British-TrainedNurse-MidwifeFrontier Nursing School and Service1925AANM 1929
18 Frances Reiter 1943 “Nurse-Clinician” Designated a nurse with advanced clinical competence
19 Clinical Nurse Specialist Adelaide A. Mayo, editorAmerican Journal of Nursing1944
20 1st Clinical Nurse Specialist Program Hildegard PeplauRutgers University, New Jersey1954Psychiatric Nursing- Master’s LevelNACNS 1995
21 1st Nurse Practitioner Programs Pediatric Nurse PractitionerLoretta Ford & Henry SilverUniversity of Colorado 1965NAPNAPAdult/Family Nurse Practitioner 1971AANPACNPNeonatal Nurse Practitioner 1977Acute Care Nurse Practitioner1995 Adult2005 Pediatric
22 APN Outcome Studies CRNAs Alice MaGaw 1899 1st outcome study Northwestern LancetCNMWsUCSF PEW Health Professions 199814 recommendations to improve practiceCNSDayhoff & Lyon 2001 CNS defined by role
23 1st NP Outcome StudyThe University of Colorado PNP Demonstration Project 1965Purpose: 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 ActsPublic Health NursingPrimary Care Physician ShortageTrend Toward Medical SpecializationConsumer MovementWomen’s MovementNeeds within the populationNursing professionHealth-care delivery systemEmphasis 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 nursesto evaluate feasibility of expandingnursing 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 existsHistorically lack of unity in requirements for entry into programsVariations in degree receivedDebate over setting for and length of programCertificate, MS, now DNPScope of practice (State vs Federal in US)
29 Standardization of Educational Preparation for Nurse Practitioners certificate programs, 74 master’scertificate programs, 84 master’s programscertificate programs 400+ master’sDNP programsDNP 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 NursingPractice:Building Curriculum for Quality NP Education(2002)
31 Common Features of APN Graduate Education The Graduate Nursing Core: generic to all master’s nursing degreesThe Advanced Practice Nursing Core: generic to all advanced nursing practiceThe specialty role core specific to each APN role
32 Graduate Core Curriculum Content I. ResearchII. Policy organization and financing of health carea. Health care policyb. Organization of the health care delivery systemc. Health care financingIII. EthicsIV. Professional Role DevelopmentV. Theoretical Foundations of Nursing PracticeVI. Human Diversity and Social IssuesVII. Health Promotion and Disease Prevention
36 National Organization of Nurse Practitioner Faculties (NONPF) 2006 Seven Domains of Practice1.* Management of Client Health/Illness Status2. The Nurse-Client Relationship3. The Teaching-Coaching Function4. Professional Role5.* Managing and Negotiating Health Care Delivery Systems6. *Monitoring and Ensuring the Quality of Health Care Practice7. Cultural and Spiritual competency
37 Sample NP Skills & Functions screeningphysical and psychosocial assessmentmanagement of common health problemsfollow-upcontinuity of carehealth promotionproblem-centered servicesidentification and mobilization of resourceshealth educationclient and group advocacy* All are aspects of Primary, Secondary, Tertiary Care
39 Quality of CareThe degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledgeInstitute of Medicine (IOM) 1990
40 Challenges to Nursing Outcome Research Patient autonomyMultiplicity of individual’s health problemsNonclinical characteristicsMultiplicity of providersUnknown time between interventions and outcomesLack of baseline measurementsComplexity of variables
41 Additional Problems Relative insensitivity of outcomes Final outcomes not known until too lateOutcomes can be influenced by outside factorsInformation about outcomes not readily availableFew lists of valid effectiveness criteria and measurementsNugent & Lambert 1997
42 Variance in Outcomes Not met at all Met later than expected Met ahead of timeVariancePositiveNegativeClassification of VarianceSystemProviderClientMurray & 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) ObservationDescriptionQuantification
45 Types of Outcomes Physiological Perceptual Psychosocial Cognitive Heart rateWeightPerceptualSatisfactionSymptom controlQuality of lifeWell beingPsychosocialAttitudeMoodCognitiveKnowledgeUnderstandingFunctionalADLsROMFiscalCostBehavioralComplianceMotivation
46 General Outcomes Length of stay Resource use Costs Patient satisfactionTechnical 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 statusTreatmentSettingEnvironment
49 Variables affecting patient outcomes Socioeconomic factors Family support Age and genderQuality 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 actionToo specific or specializedLimited meaning or generalizability
51 Principles in Determining Outcomes Must be measurableMust relate to care process/interventionMust be realisticMust be measured within accessible time spanMust describe riskMust consider costChosen parameters must be accurate and specific to care
53 Gold Standard in Early APN Outcome Research Comparative outcomesMeasured against physician careEquivalentSuperior
54 US Comparative Studies Brooten et al 1986Mundinger 2000Health Resources and Service Administration (HRSA) Bureau of Health Professions (2000) CNS & NP workforce reportsUS Congress Office of Technology Assessment 1986
55 International Comparative Studies AustraliaHorrocks, Anderson & Salisbury (2002)Chang et a (1999)United KingdomKinnersley et al (2000)Sakr et al (1999)NetherlandsLaurant et al (2004)
56 Reviews of categories of indicators for outcomes Hegyvary 1991ClinicalFunctionalFinancialPerceptualIrvine et al 1998Complication PreventionClinical outcomesKnowledgeFunctional healthCost of carePatient satisfaction
57 Classification of Outcomes Lang & Marek 1990 PhysiologicalPsychologicalFunctionalKnowledgeSymptom controlHome maintenancePt satisfactionSafetyNursing diagnosis resolutionFrequency of serviceCost & rehospitalizationWell beingGoal attainment
58 Sources of Measurement: Common Data Sets Administrative dataMedical recordsDischarge summariesSurveysElectronic medical recordsPatient/family reportsClinical practice guidelines/critical pathwaysStandardized Data SetsJCAHOCONQUESTAHRQHEDIS
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 2002Cunningham 2004Kleinpell 2001
61 Limitations in APN Studies Lack of methodological rigorUse of variable measurement strategiesLack of specific health related outcomesUse of physician as comparative groupHeterogeneous outcomesLack 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 basedRarely directed toward understanding scientific basis for clinical practiceRarely examine underlying relationship between outcomes and care
64 Beyond comparative value outcomes of APNs Unique contributions of APNsIncome“Value added”Mundinger 2000Ryden et al 2000Wong et al 2000
65 Example APN value added skills Health education integral to careDisease prevention/health promotionTeaching/counselling/listeningCoordination of careCommunity resource accessPartnerships with patients/familiesHolistic care in a family social contextAdded ‘nursing ingredient’ to APN care(Plager & Conger 2007)
66 Nurse Sensitive Outcomes of Practice ANA 1996 Set of Nursing IndicatorsJohnson & Maas 1997Nursing Outcomes ClassificationGeneric NursingCNS Literature
67 Ingersoll et al (2000) Nurse Sensitive Outcomes of APN Practice 10 indicators Perception of being well cared forTrust in providerCollaboration among providersCare provider recommendationsFrequency/type procedures orderedPt satisfactionSymptom resolution/reductionCompliance/ adherence/cooperationKnowledge of patient/familyQuality of life
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 careBourbonniere & 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.
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 199024/9/2008 The Tri-Council for NursingRobin Newhouse, PhD, RN, CNAA, BC, CNORUniversity of Maryland & Johns Hopkins University.
75 “Nursing is not second class medicine but first-class health care” Loretta Ford