1. Conceptualizations of Advance Practice Nursing
Dr. Waddah Demeh

2. Introduction :
Fundamental to sound progress of any practice is the development of a common language and conceptual framework for communication and for the guiding and evaluating practice , education , policy, research and theory.

3. practice research education policy
The development of conceptual framework is the fundamental that significantly progressing practical filed.
Framework Area of application
practice
research
education
policy
development of advance practice nurse professional (new domain of framework)

4. Think about this ..!
- What is the scope and the purpose of APN? - Is the need for APN obvious in the clinical area ? - Within what setting of practice should the APN placed ? - Do you think that APNs make a difference ?

5. Terminology : Advance practice nursing: (NCSBN)
The advance practice of nursing by NP, CNS, nurse anesthetist and nurse-midwives which based on the following:
A) Knowledge and skills acquired in basic nursing education level.
B) Demonstration of minimal competency in basic nursing (licensure).
C) Graduate degree concentration in an APN category .

6. Concept :
An idea or complex mental image of a phenomenon (object, property or event).

7. Conceptual model (C.M)
Consists of metaparadigms, philosophies, conceptual models, theories, and empirical indicators
A set of relatively abstract and general concepts that address the phenomena of interest , the propositions that describe the concepts , and the propositions that state the relationship between the concepts .
The components of the C.M are the concepts and the relationships that make a meaningful concepts.

8. Purposes:
May help APNs articulate professional role , identify and function.
Framework for organizing APN beliefs and knowledge a bout their role and practice .
- Used to differentiate among levels of nursing practice .

9. Provide testable theories through studying certain concept .[research].
Plan curricula in faculties and make choices a bout course content and clinical experiences .[education].

10. Problem and imperatives:
( for conceptualization of APN) - Three areas of conceptual confusion can be identified : 1) There is an absence of well defined and consistently applied terms of reference .(e.g: the building blocks use, domains , roles , hallmarks, no universal meaning).

11. Problem and imperatives:
Shuter & Davis(1993) stated that one of the greatest barrier to using nursing model in practice relates to vocabulary and communication within the model

12. Problem and imperatives: 2) Attempts to articulate models of APN failed to consider the existing literature . The article which published in 2001, the working of this article start in 1990, this make lag between conceptualization and ultimate publication

13. Problem and imperatives:
3) Lack of clarity regarding conceptualizations that differentiate between levels of clinical practice (How APN is different from that of experienced nurses (non-master nurses ).

14. Problem and imperatives:
4) Need to clarify differences between advanced practice nursing and medicine 5) Interprofessional education and practice (e.g.with medicine )

15. Why do we need to reach consensus on conceptualization of the nature of APN ?
1) Differentiation of APN from other levels of nursing practice . 2) Differentiation between APN and the clinical practice of other non nurse provider . 3) Clear understanding of roles and contributions of APNs on interdisciplinary teams health care outcome.

16. 4) Delineation of the similarities and differences among APN roles
4) Delineation of the similarities and differences among APN roles . 5) Regulation and credentialing of APNs 6) Clear articulation of international, state, and local health policies 7) Maximum social contribution by APNs in health care (e.g. ↑ quality ) 8) Actualization of practitioners of APN.

17. Professional organization's conceptualizations :
- American Nurses Association . - American Association of colleges of nurses. National organization of nurse practitioner faculties - National Association of Clinical Nurse Specialists. - American Association of Nurse Anesthetist and American College of Nurse – Midwives.

18. The benefit of professional organization's conceptualization:
These models provide a templates against : 1- Levels of practice can be distinguished . 2- Educational programs can be developed and evaluated .

19. 3- Knowledge and behaviors can be measured for certification purposes .
4- Practitioners can understand, examine
and improve their own practice .
5- Job descriptions can be developed

20. Addresses elements of nursing’s metaparadigm
Key Assumptions about Profession Philosophy, Values, and Practice in Conceptual Models
Addresses elements of nursing’s metaparadigm
Depends on professional agreement regarding nature of advanced practice nursing
Will reach full potential to extent that components of any model are appropriately delineated and agreed upon

21. Consensus Model for APRN Regulation

22. Criteria for APRN
Completes accredited graduate-level education program in APRN role
Passes national certification exam
Possesses advanced clinical knowledge and skills for providing direct care
Builds on RN competencies
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

23. Criteria for APRN (Cont.)
Educationally prepared to assume responsibility and accountability for advanced practice
Sufficient depth and breadth of clinical experience to reflect intended license
Obtains license to practice in APRN role
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

24. Direct Care
Providing direct care to individuals is a defining characteristic of all APRN roles
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

25. Graduate Education
Must include advanced physiology/pathophysiology, health assessment, and advanced pharmacology
Must address: Principles of decision making, core competencies, and role preparation in one of six population foci
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

26. Licensure
Must be based on educational preparation on one of four roles and a population focus and certification within the same area
Preparation in specialty cannot be basis for certification
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

27. Limitations
Competencies
Specialization: e.g. regulatory focus

28. American Nursing Association (ANA)
ANA published a revision of nursing social policy statement in (2010). This statement include concept that differentiate APN from basic nurse
This concept as :
specialization
expansion
advanced practice

29. Expansion
Horizontally acquisition of new practice knowledge and skills that legitimate (role autonomy) within area of practice that cause overlap traditionally boundaries of medical practice.

30. Specialization
Vertically concentrate to part of the whole filed of nursing

31. Advanced practice: Examples of certified ANA:
Characterized by the integration of a broad range of theoretical, research-based, and practical knowledge that occurs as part of graduate education (ANA, 2010)
Examples of certified ANA:
Certified nurse midwife (CNMs)
Certified registered nurse anesthesia (CRNAs)

33. National Association of Clinical Nurse Specialists (NACNS):
- NACNS published a statement on clinical nurse specialist practice and education in 1998 and revised it in Their focusing was on differentiate CNS practice from that of other APNs and proposed a new statement to resolve the ambiguity a bout this particular APN role .

34. Three sphere of influence are posited :
patient,
nurses and nursing practice , and
organization \ system .
Each of which requires a unique set of competencies (NACNS, 2004) .
In addition , the statement outlines expected outcomes of CNS practice for each sphere.

35. Need further clarification:
The model define the CNS , essential characteristics , description of spheres of influence and associated competencies and recommendations for graduate
Need further clarification:
Between the 2004 Statement on CNS Practice and Education and the 2010 CNS Competencies
The population focus, not specialization, is the basis for regulation.

37. American Association of Nurse Anesthetist and American College of Nurse – Midwives : (AANA)&(ACNM)
- official statements of AANA (1996,2002) and ACNM(1997,2003) describe the advanced nursing practice models of certified registered nurse anesthetists and certified nurse –midwives. - These statements include scopes of practice , standards and other documents that describe CRNA and CNM practices .

38. -The most recent revision of the AANA's scope and standards in 2010 , define the scope of practice followed by 10 items that could characterize as clinical competencies or responsibilities (e.g managing a patient's airway ). Followed by “seven additional responsibility and eleven standards .”

39. The purpose of the standards to :
1) Provide a guide for evaluating CRNA care 2) Help in development of quality practice. 3) Help the public understand what they can expect from CRNAs. 4) Support the basic rights of patients

40. American College of Nurse-Midwives (ACNM)
CNMs are educated in nursing and midwifery (ACNM, 2011)
Competencies “describe the fundamental knowledge, skills, and behaviors of a new practitioner” (ACNM, 2012)
Does not support DNP as requirement for entry into nurse-midwifery practice

41. Conceptualization of the nature of APN:
In this section the focus is on those framework that address the nature of advance practice nursing

42. 1.HAMRICS' MODEL OF ADVANCE PRACTICE NURSING :
One of the earliest efforts to synthesize a model of Advance Practice that would apply to all APN roles was developed by Hamric (1996). Hamric model: proposed of conceptual definition of APN and defining characteristic that include:

44. 2. Browns framework of APN
Browns synthesized existing literature to propose a conceptual framework that included four domain and seventeen specific concept:

45. 1. Environment: It is the surround and impact upon practice include: society, health care economy, local conditions, nursing, and advance practice community 2. Role legitimacy: Include graduate education, certification, and licensure

46. 3. Advance practice nursing: the important and centered concept Include: scope, clinical care and competencies, managing health care environment, professional involvement in health care discourse (communication) 4. outcomes: Include patient, health care system, nurse profession, and individual APN outcomes

47. Browns recognized the activity of professional health care (APN’s):
* focus on clinical services rather than nurse client interface. * use a Nursing Orientation Program. * have a defined, but dynamic and evolving scope: knowledge accrues lead to practice change * based on competencies that are acquired through graduate nursing education

48. Brown’s Framework for Advanced Practice Nursing
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.

49. 3. Oberle and Allen: the nature of Advance Practice Nursing :
- According to Oberle and Allen 2001 any conceptualization of advance practice nursing should be embedded in a conceptual understanding of nursing . - They refer to practice as (praxis) a term that captures the values –oriented , reflective , and creative nature of the work of nurses .

50. They conceive of nursing as a dialectic (back and forth) process between the nurse's knowledge and his or her experiences and relationships with patients .
Oberle and Allen differentiate between experts by experience and APNs as follows : " the inherent difference between expert and advance practice is that the expert nurses knowledge base in largely experientially acquired , where as the APN has a greater store of theoretical knowledge acquired through graduate study ".

51. Oberle and Allen propose that graduate education is a process in which students have experiences that lead to " transformative practice " .

52. APN’s
Expert by experience
Knowledge Acquired through graduate study
Knowledge Acquired through experiences
Experience having through education (transformation practice)
Experience through trail and error
Have a starting point through article and model (evidence based) of algorithm
Not evidence based by recurrent trying to perform the action

53. Models that APNs will find useful in their practice :
- Models useful for differentiating levels of nursing practice . - Models useful for studying outcomes of APN. - Models useful for conceptualizing interdisciplinary practice.

54. Model useful to differentiate level of nursing practice

55. The American Association of Critical Care Nurse's Synergy Model :
- It is an effort to link nursing practice with patient outcomes (Curley ,1998).
model component:
1. patient characteristics
2. nurses competencies
3. outcomes (on patient, nurse, system)
- This model is useful for certification examinations and could use to structure curricula .

56. patient characteristics
Health and Vulnerability to illness are influenced by biologic, genetic, psychological, and socioecologic determinants .
Each patient characteristic ranged from 1-5
(1: reflect illness state and 5 reflect health and safe state)

57. AACN(2007) stated the patient characteristic include the following: resiliency: the capacity to return to a restorative level of functioning the body mechanism vulnerability: susceptibility to actual or potential stressors that may adversely affect on outcomes stability: the ability to maintain steady state equilibrium

58. Complexity: distribution to choice on or more system (body, family…) .
predictability : allow the patient to expect a certain type of care .
resource availability: the extent of resources (psychosocial, patient-family-community interaction) .
participation in care and decision making : the ability to engage in aspect of care and decision .

59. Patient characteristic
1 minimal
3moderate
5 very high
resiliency
Unable
Simple
Strong enable
vulnerability
Unprotected (high)
Somewhat protected
Safe (minimal)
stability
Unstable and high risk
Stable with limited time
Stable, low risk
Complexity
Complex patient family dynamic (high)
Moderate patient family dynamic
Minimally family dynamic (low)
predictability
Not predictable
Limited predictable
Full predictable
resource availability
Few resources
Limited resources
Many resources
participation in care and decision making
No participation
Low level of participation
Full participation

60. Example of patient characteristics: Adult patient in case of chronic hypertension: may full predictable, high resiliency, not complex, not vulnerable, can decision about care and has adequate resources, stable Infant patient in case multi-organ failure: unstable, high vulnerability, unable to decision the care, unpredictable.

61. nursing competencies
- An important function of the nurse is to ensure the patient's "safe passage " through the health care situation . - Nursing competencies are derived from the needs of patients and also exist a long continue - These competencies ranged from 1-5 (1: competent nurse while 5 expert nurse)

62. nursing competencies There are eight nursing competencies continue :
Clinical judgment,
Advocacy and moral agency,
Caring practices,
Collaboration ,
Systems thinking ,
Response to diversity,
clinical inquiry or innovator, evaluator,
Facilitator of patient and family learning ,

63. AACN (2007) stated the nursing competencies include the following: clinical judgment: include clinical decision making, critical grasping of the situation advocacy and moral judgment: concern within and outside clinical setting

64. caring practice: nurses activities that support the patient environment including family health care . collaboration: working with others (patient, family, and care giver) to optimize realistic goals system thinking: the knowledge and tools that allow the nurse to manage with patient environment and system

65. Responses to diversity: give different responses in caring according the situation, ethnicity, life style … clinical inquiry : become innovator and evaluator Facilitation: ability to facilitate the learning for patient, family other care provider…

66. Nursing competencies
(1) competent nurse
(5) expert nurse
Clinical judgment
Follow algorithm and decision tree
Multiple interpreting data, sometimes conflicting
advocacy and moral judgment
Make ethical decision depend on rules
Suspend rules and advocate and ethical decision will be initiated
caring practice
Care according standard and protocol
Awareness and anticipated patient and family change
collaboration
Working with others regarding patient care
Working with others regarding patient care and seek opportunities to teach and coach others
system thinking
Use limited strategies
Develop and integrate and apply many strategies
Responses to diversity
Provide care according own belief
Provide care consider different culture and value
Facilitation
Follow planned education program
Creativity and develop patient family education program
clinical inquiry
Follow guideline
Improve standard and technique

68. Outcomes:
outcomes is important for patient, nurse and system patient outcomes : the patient trust of the care giver and patient satisfaction nurse outcomes: physiological outcomes by using interventions and nurse satisfaction

69. system outcomes: derived from hospitals or insured by re-admission patient to hospitals for preventable complication

70. Important of this model:
Recognizes the importance of nurse patient relationship and patient’s trust in caregivers.
certification of the nurse depend on nursing competencies.
the competencies help to prepare APN program for complex and simple cases .
differentiate among critical care APN roles e.g CNS and NP have a different competencies

71. Model useful for studying outcomes of advance practice nursing

72. 1. Brooten’s model of transitional care
Brooten et al (1988) integrated outcome, patient satisfaction, and cost to evaluate the outcome of APN transitional care.
Brooten et al (2002) stated the APN transitional care is defined as “comprehensive discharge planning designed for each patient group plus APN home follow up through a period of normally expected recovery or stabilization”

73. Methods:
Review of published results of seven randomized clinical trials with very low birth-weight (VLBW) infants; women with unplanned cesarean births, high risk pregnancies, and hysterectomy surgery; elders with cardiac medical and surgical diagnoses and common diagnostic related groups (DRGs); and women with high risk pregnancies in which half of physician prenatal care was substituted with APN care.

74. Findings
APN intervention has consistently resulted in improved patient outcomes and reduced health care costs across groups. Groups with APN providers were re-hospitalized for less time at less cost, reflecting early detection and intervention. Optimal number and timing of post-discharge home visits and telephone contacts by the APNs and patterns of re-hospitalizations and acute care visits varied by group

75. Brooten’s Factors that Contribute to APNs’ Effectiveness
Content expertise
Interpersonal skills
Knowledge of systems
The ability to implement change
Ability to access resources

76. Nurse dose depends on patient and nurse characteristics
The concept of nurse dose may enable the profession to differentiate more clearly among novice, expert, and advanced levels of nursing practice.

77. Conclusions
- To keep people well over time, APNs must have depth of knowledge and excellent clinical and interpersonal skills that are the hallmark of specialist practice, an in-depth understanding of systems and how to work within them, and sufficient patient contact to effect positive outcomes at low cost. - Support for a broad conceptual model of APN practice that encompasses APN characteristics, competencies, patient factors, environment, and other concepts that can inform role specific models

78. Model useful for conceptualizing interdisciplinary practice

79. Dunphy and Winland –Brow's circle of caring : A transformative collaborative model .
A central premise of Dunphy and Winland- Brown's model (1998) is that the healthcare needs of individuals , families and communities are not being met in a healthcare systems that is dominated by medicine .

80. - The circle of caring model is said to incorporate the strengths of medicine and nursing in a transforming way . - The conceptual elements are the processes of assessment , planning intervention and evaluation with a feedback loop . - The assessment – planning- intervention- evaluation processes in linear configuration are encircled by caring .

81. They proposed the circle of caring:
a transformative model in order to foster a more active and visible nursing presence in the health – care system and to explain and promote medical – nursing collaboration

82. - Caring is actualized through interpersonal interactions with patients and care givers to which NPs bring patience, courage, advocacy, authentic presence, commitment and knowing.

84. Conceptualization of Advanced Practice Nursing :
Rigorous content analysis of the statements published by professional organizations that describe the APN. e.g. APRN consensus model work.
A similar content analysis of statements addressing advanced nursing practice promulgated by specialty organizations
A review of recent role delineation studies of the four APN roles.
Integrative review of APN literature
Based on no. 1-4, synthesis of results of suggested reviews to propose definition of advanced practice nursing

85. Use above analysis to evolve common structure for organizational statements about APNs
Evolve similar structure for developing statements about each organization’s approach to advanced practice nursing
Use nos. 1-5 to address APN documents addressing licensing, accreditation, certification and educational issues (LACE) for existing and new APN roles
Revisit work on definitions referring to APN work

86. Consensus building a round APN :
Collaboratively developed conceptualization of APN and what is common across roles is prerequisite for consensus building
APRN Consensus Model represents substantial progress in area regarding regulation
Need ongoing development of consensus
Responses from professional organizations to the DNP initiative likely to influence evolution of APN in next decade

87. Consensus on Key Elements of Practice Doctorate Curricula
Disagreements about elements of curricula are emerging
APN organizations have prepared doctoral level competencies consistent with those proposed in DNP

88. Research on APN practice and outcome :
- Research on patient outcome and cost effectiveness that lead to increase the knowledge a bout APN in critical . - Conceptual models of APN should be refined based on research for the purpose of validating the key concepts .

89. - Research should examine interpersonal skills, communication skills are important to examine the link between less tangible aspects of APN care and patient outcome .
- Examine advanced practice nursing across APN roles and between physician and APN practice
- As conceptualizations of interprofessional teams evolve, ensure research on role of APNs
- This better understanding of the roles should be presented to colleagues from other disciplines , policy makers and public

90. Summary :
A stable, robust model of advanced practice nursing will serve to guide the evolution of advanced practice nursing and ensure that patients will have access to APN care A unified conceptualization of advanced practice nursing will focus the efforts of the profession on preparing APNs, promulgating policies, and fostering research that can enable the realization of desired outcomes