DR. WADDAH DEMEH

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Advanced Practice Nursing

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Role, as a concept, is useful in interpreting personal behavior with significant others and in understanding the context in which behavior takes place.

Role theory emphasizes the notion that human behavior is not a simple matter of stimulus–response reaction, but the result of a complex interaction between ego and society.

It synthesizes the culture, the social structure, and the self by considering culture and social structure from the individual’s level.

Introduction

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Introduction

There are three major schools of thought in role theory:

views roles as culturally given prescriptionsdefines role in terms of the actions and expectations of individual members of a societyconceives of role as stemming from interaction with actors in a social system. In this school, role emerges in a designated reciprocity in which an interaction or a social exchange occurs and is seen in terms of relevant other roles.

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Through interaction and the role-taking processes with the significant other, each person’s role are discovered, created, modified, and defined. These roles are thus incorporated in the ego’s self-conception. In general terms, then, self-conception is actually a conception of how one relates to major significant other roles.

Introduction

Trends that accompanied the development of APN:

1. Inter and intra-professional conflicts2. Societal forces; wars, advances in science & technology, federal government funding & legislation, economic conditions, gender issues, & women movement.3. Organizational efforts, certification and movement toward graduate education .

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Introduction6

The term nurse specialist can be traced to the turn of the 20th century ( a nurse who had completed a postgraduate course in a clinical specialty or had extensive experience in a certain clinical area )

During the 1960s & 1970s, with the introduction of the NP role, the terms expanded role and extended roles were used indicating a horizontal movement to include expertise from medicine and other disciplines.

During 1980s the term advanced practice appeared as a vertical movement.

Since 1980s, state nursing practice acts adopted the term advanced practice to indicate CRNAs, CNMs, CNSs, & NPs

Definition of Terms7

Specialization: a concentration on one of the four APN specialty areas (CNS, NP, NM, NA).

Expansion: the commitment for ongoing learning and acquisition of new knowledge, skills &

competences.Advancement: involves both specialization &

expansion, & results in new integration of theory, skills & competences to respond to the needs of

patients/families & an evolving health care system.

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Specialista nurse who had completed a postgraduate course in a clinical specialty area or who had extensive experience and expertise in a particular clinical practice areaExpanded Role and Extended Roleimplying a horizontal movement to encompass expertise from medicine and other disciplines

Advanced Practicereflects a more vertical or hierarchical movement encompassing graduate education within nursing, rather than a simple expansion of expertise by development of knowledge and skills used by other disciplines

Definition of Advanced Practice Nursing

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The performance of additional acts by registered nurses who have gained added knowledge and skills through post-basic education and clinical experience.

“ advanced clinical practice”

NP, CNS, CNM,CRNA

Commutative Index to Nursing & Allied Health Literature

Advanced practice registered nurses

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Registered nurses who have attained advanced education and expertise and specialize in such medical fields as pediatrics, anesthesiology, gerontology, neonatology and mental health. APRNs include nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified nurse anesthetics (ANA 2003)

Pre-1930s: The roots of Advanced Practice Nursing

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2 events occurred during 19th century: American Civil war (1861-1865) Discovery of Chloroform

These led to birth of professional nursing in USA and the roots of specialty practice in nurse anesthesia.

Mother of anesthesia (Alice Magaw)

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The Roots of Nurse Anesthesia

The specialty of nurse anesthesia emerged directly from the pre-professional work of women in the Civil War

Part of the nurses’ work included assisting in surgery, particularly with the administration of chloroform

The creation of training schools for nurses was a direct outcome of the war

The Roots of Nurse Anesthesia 13

Alice Magaw Mother of anesthesiaFelt that the responsibility for administering anesthesia

should be given to nurses rather than physicians in training—nurse anesthetists concentrated on

administering the anesthesia rather than observing the surgery

Helped separate hospital-based anesthesia services from the traditional nursing service administrative structures

The Roots of Nurse-Midwifery14

Throughout the 18th and 19th centuries, lay midwives, rather than professional nurses or physicians, assisted women in childbirth.

Untrained "old country midwives” would lose respect later in the century as “scientific” hospital–based deliveries became the norm.

Women in isolated communities throughout the country, particularly in rural settings, continued to use midwives for deliveries well into the 20th century.

The Roots of Clinical Nurse Specialization: Psychiatric Nursing

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Recognized as the first clinical specialty in nursing

Had its origins in the reform movement initiated earlier in the century by Quakers at the York Retreat in England

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Linda RichardsOrganized a nursing school for the

preparation of psychiatric nurses at the Worcester Hospital for the Insane

Is credited with founding the specialty of psychiatric nursing

The Roots of Clinical Nurse Specialization: Psychiatric Nursing

1930s-1950s:The emergence of advanced practice nursing in the USA

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1933( Roosevelt): economic depression Rural rehabilitation programs, including health programs, sponsored by the Farm Security Administration (FSA) were developed for poverty-stricken farmers and their families

Private hospitals forced to close nursing schools No student labor employed graduate nurses+ unemployed private duty nurses = nurses gave up autonomy and freedom to bill their services to work in physician dominated hospital bureaucracies and be considered as part of room rate.

1950s:The growth of hospitals and scientific nursing

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Research and scientific knowledge advances in medical science & technology specialization & scientific approach to medical care.

Federal government Hospital Survey & Constriction Act Federally funded hospital construction modernize old hospitals & open new ones eliminated large open wards long halls with private & semiprivate rooms + increasing severity of illness +nursing shortage grouping of very sick patients requiring observation in one place (ICU) required nurses with specialized knowledge & skills increased specialization in nursing

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•Post war period Federal government supported nurse education nurses returning from world war II returned to school and many were eligible for advanced Education + National League for nursing Education (NLNE) Cataloged all nursing programs, including MSc programs + support by government of the importance of graduate Education for nurses

1960s: Innovation & growth in Advanced Practice Nursing

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Federal legislation of the great society +national problem of heart disease +Vietnam war Congress passed the Nurse Training Act (NTA) funding nursing education.

NTA provided financial packages for student grants and loans + constructing nursing schools + faculty recruitment & development.

President Johnson-plans for the Great society-legislation to Medicare & Medicaid---health care benefits for Americans (combating cancer & heart diseases)

ANA published the 1st position on education for nurses requiring nursing education to be housed in colleges & universities & laid foundation for postgraduate education.

1970s: Advanced Practice Nursing becomes established.

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Public consensus that nursing should expand its scope to provide direct services to patients including those previously done by physicians.

Richardson; Secretary of Health, Education, & Welfare issued a report “ Extending the scope of nursing practice”

The report called for nurses in primary, acute, & long-term care to expand their responsibilities to collect medical data & make clinical decisions

ANA published educational standards, described the NP & CNS roles, & defined the expanding scope of nursing practice.

Nurses struggled to identify the boundaries of the discipline & scope of APN.

Women MovementAbortion

Disillusion with governmentResistance to Vietnam war

Health care for the handicapped

1980s: APN matures and expands22

To provide leadership for institutionalizing APN in the health care system, the ANA issued the ANA’s Social Policy Statement which declared the specialization in nursing is now clearly established.

Lack of consensus about educational preparation of APNs and the titles to identify them continued to plague the profession.

The concept of ANP began to be defined & used in the literature

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•Increasing emphasis on cost containment in the 1980s influenced APN & the whole health system: - establishment of payment system using DRG ( capitation) increase pressure on nurses & physicians to save money by reducing length of hospital stay. - budget cuts nursing administrators to evaluate the cost effectiveness of CNCs & eliminating some of these positions•The need for cost effectiveness, quality care promoted the Senate Committee on Appropriation to request a report on the contribution of NPs & CNMs in meeting the nation’s needs. It concluded that “within their areas of competence NPsand CNMs provide care whose quality is equivalent to that of care provided by physicians”•The AMA House of Delegates passed a resolution to oppose any attempt at empowering non-physicians to become unsupervised Primary care providers & be directly reimbursed.

1990s: APN responds to managed care24

The 1990s opened with the USA war with Iraq. Thousands of nurses were sent to the Gulf.

High concern with cost.Need for health care reform (P-Clinton).ANA had a proactive position and wrote its

Agenda for health care reform (1992).Radical changes were made by the private

sector ( fee for service) taken by managed care organizations

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Market place created new challenges for nurses:

Restrictive outdated state laws on prescriptive authorityNon-governmental, market-based impediments of APNs’ practices.

APNs continued to expand their roles, educational Preparation and practice settings.

The national Nursing Summit in August 1993, master’s education for APN was agreed upon.

The 21st century: New challenges & opportunities for APN

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Computerized charting, widespread use of internet, emphasis on evidence-based practice, & increasing awareness of the global community.

The threat of infectious disease from bioterrorism became a reality after September 11 calling for public health nursing and the rebuilding of the public health system.

Increasing percentages of the uninsured and underinsured.Aging population.Wars and conflicts with Iraq and Afghanistan.The critical nursing shortage.

Full recognition of APNs by insurers and managed care organizations is currently the most important challenge

Conclusion27

APNs have been permitted by organized medicine and legislation to care for the underserved, yet, competing with

physicians’ reimbursement lead to inter-professional conflicts.

Documentation (through evaluative research) of the contribution of APNs to the health care system is required.

Need for certification and graduate education.Presence of inra and inter-professional resistance to

expanding the scope of practice.Evolution of APN has been influenced by wars, economic

climate, and health care policy.